Lymphatic surgery

Lymphaticovenous anastomosis (LVA)

• Works where functional lymphatics are seen on ICG; complications about 1%. Lee 2025 · Gaxiola-García 2024
• Cellulitis: LVA added to decongestive therapy cut cellulitis by 0.35 episodes per 6 months (−0.62 to −0.09), but 111 of 336 randomised were excluded, 69 refused their arm and the LVA arm started with almost twice the cellulitis rate (regression to the mean) — very low; no effect on circumference or pain. Before–after series show the same fall. Mihara 2024 · Mihara 2014
• Who responds: dilated vessels and dermal backflow on lymphoscintigraphy predict response; in primary leg lymphoedema, onset age guides selection. A quarter of legs worsened after multisite LVA. Chiewvit 2017 · Hara 2015 · Mihara 2016
• Technique: side-to-end and end-to-end anastomoses differ by about 1%; overlapping lock-up LVA (10 patients, 7-day patency only); ICG-targeted drainage after leg LVA (unblinded, retrospectively registered) — very low. Robotic LVA (MUSA pilot) was feasible but slower, with developers holding company shares. AlJindan 2019 · Zheng 2024 · Wang 2026 · van Mulken TJM 2020
• Quality of life: pre–post gains (SMD 0.86) without controls; pooled QoL benefit not shown (SMD 0.77, −1.17 to 2.70) — very low. Zurfluh 2025 · Kumar 2026 · Grünherz 2021
• Pregnancy after LVA did not worsen leg lymphoedema (5 cases); robotic periorbital LVA is a single case report. Koshima 2019 · Imholz 2025

Vascularised lymph node transfer (VLNT)

• Better suited to advanced disease; donor-site lymphoedema is the main risk. Perets 2024
• Pooled series: arm VLNT ~40% reduction in volume difference, donor complications 12%; leg VLNT ~25% reduction, complications ~16% (venous congestion 7%), with count errors and probable duplicate data; reoperation 26% and lymph leak 32% reported beside an "OR 7 for excellent results" — all very low. Winters 2022 · Shah 2026 · Kong 2022
• Harms: an independent clinic series found no volume gain and 38% complications; donor-leg lymphatic injury is often subclinical and is reduced by limited harvest. Adding a node flap to free-flap breast reconstruction did not raise 30-day complications. Vignes 2013 · Viitanen 2012 · Sulo 2015 · Chiang 2023
• Comparisons (non-randomised): groin VLNT v physiotherapy; VLNT v LVA or CDT (advantage confounded by stage, longer follow-up and later liposuction); supraclavicular VLNT v LVA in advanced legs; VLNT plus LVA was no better than VLNT alone (revised 2026-10-11). Cheng 2013 · Engel 2018 · Akita 2015 · Di Taranto G 2021
• Double VLNT with radical reduction for stage III; node flap with laser liposuction; Charles excision plus node flap for end-stage legs — series only. Ciudad 2019 · Nicoli 2015 · Sapountzis 2014
• ICG lymphography can track the effect of surgery. Chen 2016

Prevention at the time of cancer surgery

• ILR: the Coriddi RCT is the best evidence (above). Pooled studies: RR 0.41 (NNT 9) for early BCRL, but 8 single-arm studies used a borrowed control rate and the benefit was lost after 3 years — low (early), very low (lasting). Across cancers 7.1% v 35.0% (RR 0.31), mostly non-randomised — low. An earlier review's 6.6% v 30.5% used 17 patients in whom ILR was abandoned as controls — very low. Li 2025 · Hinson 2025 · Cook 2022
• Groin and pelvis: ILR prevents ~30 per 100 cases after iliofemoral lymphadenectomy but may worsen oncological outcome in limb skin cancers. Gloviczki 2026
• Axillary reverse mapping showed no difference in patients' own ratings; reverse ICG mapping in melanoma SLN surgery. Gennaro 2022 · Hsu 2025

Reductive surgery: liposuction and excision

• Liposuction (Malmö and others): 97% of excess removed at 12 months, skin blood flow normalised, lymph transport not further impaired, ICG patterns not worsened, erysipelas −87%, QoL better than compression alone — all developer or before–after series with compression as a co-intervention. Pooled ~92% excess-volume reduction comes from case series with inconsistent counts and overlapping cohorts; its infection estimate cannot be traced — very low. Brorson 1997 · Brorson 1998 · Chen 2023 · Lee 2016 · Brorson 2006 · Damstra 2009 · Chen 2025
• In the one end-stage leg case, compression alone removed 75% of the excess before liposuction. Lymphatic grafting then liposuction: 18/28 off compression. IPC added to CDT before LVA (sequential allocation). Brorson 2008 · Baumeister 2020 · Campisi 2023
• ISL position changed from "discouraged" (1995) to acceptance for non-pitting, fat-dominant disease (2003 on), driven by proponents' own series against Földi's objections; the 2007 debate is still unresolved. Liposuction in filarial legs was reported as "disastrous" (India). International Society of Lymphology Executive Committee 1995 · International Society of Lymphology 2003 · Campisi 2004 · Cheville 2007
• Excision: end-stage leg excision of subcutis to deep fascia; radical excision with delayed grafting lasting 15 years; penoscrotal excision (40 men; 33% recurrence in another series); modified scrotal technique from Cairo. Kim 1998 · Dumanian 1996 · Guedes Neto HJ 1996 · Azadgoli 2019 · Atta 2018

Experimental and historical

• Not effective or unproven: stem-cell (ADRC) lipotransfer to the axilla had no benefit over placebo, and the authors advise against it; cell therapy is mainly animal data; omental transfer is case series only; BioBridge collagen scaffolds revive Handley's 1908 thread lymphangioplasty (the manufacturer's CTO and CEO dispute this in letters). Andersen 2024 · Lafuente 2021 · Jarvis 2021 · Egorov 1994 · Witt 2023
• Historic benchmarks: Mayo excision 1936–1964, Kinmonth's flap reductions, the first lymph vessel transplants, and why early shunts disappointed. Sakulsky 1977 · Kinmonth 1975 · Baumeister 1981 · Clodius 1981
• Lymphatic vessel grafting (Munich, 1980–2014): 380 patients; arm volume difference reduced by >50% in 70% at 2.5 years, legs less durable — developer series, very low. Subcutaneous silicone tubes bypassing groin or axillary obstruction (150 patients, with IPC and penicillin) — developer series, very low. Baumeister 2017 · Liu 2021
• MR lymphangiography for planning; Cochrane review of microsurgery v CDT under way (strong protocol; declared interests include a compression-garment consultancy and a 3M advisory board). Forte 2021 · Haas 2025

For the therapist

• Before referral: document at least 3–6 months of compliant conservative care with minimal pitting and a stable weight; record baseline volumes.
• After surgery: compression continues — lifelong after liposuction, reduced stepwise after LVA or VLNT if the limb is stable; watch the donor site after node transfer.
• Tell patients: surgery is not a cure; the largest LVA trial found no benefit at 6 months (low).
• Certainty: all reconstructive and reductive surgery low to very low.

For a vascular surgeon in South Africa

• LVA needs supermicrosurgery and ICG imaging, which are scarce in SA (LAOSA 2018 notes not all procedures are offered). LVA proved feasible in Sri Lanka (8 legs, −13% circumference). Hadiwattage 2019
• Before any operation: at least 3–6 months of compliant CDT with minimal pitting, weight optimisation, and duplex or IVUS to exclude venous outflow disease (present in 4.6–15.4% of limb lymphoedema); avoid operating in the axilla or groin in primary lymphoedema. Schaverien 2022 · Gloviczki 2024
• Most relevant to vascular and surgical-oncology practice: liposuction for fat-dominant disease, ILR or node-sparing at groin and pelvic dissection, and excision for genital or end-stage filarial disease.
• Do not cite the anonymous "clinical guide". Unknown unknown

Textbooks

Cheng 2016 · Harder 2024 · Schaverien 2022 · Baumeister 2017