ABSTRACTBackground Lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) are established microsurgical options for chronic lymphedema. This PEER umbrella systematic review synthesizes evidence from systematic reviews and meta-analyses to define indications for lymphatic microsurgery and inform forthcoming practice guidelines of the American Venous Forum (AVF) and the American Vein and Lymphatic Society (AVLS). Methods A systematic search of multiple electronic databases identified English-language systematic reviews and meta-analyses published between 2010 and 2025 addressing microsurgical treatment or prevention of lower-extremity lymphedema (LEL). Eligible studies reported objective and/or patient-reported outcomes and addressed clinical questions prioritized by the AVF/AVLS Guideline Committee. Results Twenty-six systematic reviews, including 14 meta-analyses, were analyzed; no randomized controlled trials were identified. Twenty reviews evaluated treatment of LEL, 16 also included upper extremity lymphedema: six assessed immediate lymphatic reconstruction (ILR) following tumor excision with inguinal lymphadenectomy. Conclusions were primarily driven by four moderate-quality treatment reviews and one high quality prevention review that satisfied all critical AMSTAR-2 domains. Due to substantial overlap of primary studies across reviews, findings were synthesized qualitatively and effect estimates were not pooled to avoid double counting. Both LVA and VLNT were effective. LVA was more commonly performed in earlier disease stages. Limb volume/circumference reduction ranged from 34.16% (95% CI, 23.93–44.40) to 46.8% (95% CI, 43.2–50.4), with follow-up from 1 month to 8 years (Evidence C, Low to very low quality). Postoperative cellulitis, reported in 12 reviews, decreased by 2.1 episodes/year after VLNT (95% CI, −2.7 to −1.4) and from an annual incidence of 0.84 to 0.07 following LVA (Evidence B: Moderate quality). Symptoms or quality of life improved in 50–100% of patients across 17 reviews. No deaths or major complications were reported; minor complications were more frequent after VLNT. ILR reduced the risk of LEL by 30.3 per 100 patients treated compared with no ILR (risk difference −30.3%, 95% CI, −46.5% to −14%; pConclusions Evidence supports LVA for both primary and secondary LEL when functional lymphatic channels are identified, irrespective of disease stage. VLNT may provide greater benefit in advanced disease but is associated with higher morbidity. ILR is supported for the prevention of LEL following pelvic or truncal oncologic surgery with iliofemoral lymphadenectomy but should likely be avoided in extremity dermatologic malignancies. Guideline recommendations should emphasize shared decision-making and incorporate patient preferences, procedural cost, available technology, and surgeon expertise.
Gloviczki et al. (Fri,) studied this question.