Immediate Lymphatic Reconstruction Drastically Lowers Lymphedema Incidence in Axillary and Inguinal Lymphadenectomy: A Systematic Review

Abstract

BACKGROUND: Secondary lymphedema remains one of the most notorious complications of axillary lymph node surgery following mastectomy. There is a lack of high-level evidence on the effectiveness of immediate lymphatic reconstruction (ILR) in preventing secondary lymphedema. However, ILR is beginning to be more accepted by plastic surgeons to decrease the incidence of lymphedema. Therefore, lymphedema outcomes from ILR are needed now more than ever. We evaluate ILR outcomes for the prevention of secondary lymphedema in axillary and inguinal lymphadenectomy patients. The purpose of our study was to analyze the outcomes of ILR where the main mechanism was lymphaticovenous anastomosis/bypass. This includes direct shunting of lymphatic fluid to the venous system. Additionally, we provide our own suggestions for this specific mechanism of ILR and what future studies should be done to provide more outcomes to increase the effectiveness of ILR. METHODS: The authors conducted a review of all English language articles between 2009 and 2020 in PubMed, Embase, and Web of Science, reporting original outcomes on different methods of ILR in preventing secondary lymphedema, according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Overall incidence timeline of lymphedema in patients postoperatively, postoperation complications, and surgical techniques were recorded and analyzed. We excluded non-ILR interventions, literature reviews/letters/commentaries, and non-human or cadaver studies. Risk of bias was assessed. A total of 789 patients that were enrolled in 13 studies were included in our one-arm meta-analysis. RESULTS: A total of 13 studies encompassing 789 patients met inclusion criteria: upper extremity ILR (n = 665) and lower extremity ILR (n = 124). Females accounted for 99.4% of the patients studied for upper extremity ILR, while men (69.4%) consisted mostly the lower extremity ILR cohort. The overall incidence of lymphedema for upper extremity ILR was 2.7% (95%CI: 1.1%–4.4%, P < 0.001), and lower extremity ILR was 3.6% (95%CI: 0.3%–10.1%, P < 0.001). For upper extremity ILR, the average follow-up time was 11.6 ± 7.8 months and the LE incidence appeared to be the highest around 1–2 years postoperation. ILR procedural time for upper extremity was 45.1 minutes (95%CI: 31.4–58.9 minutes) and lower extremity was 95.1 minutes (95%CI: 75.5–114.7 minutes). Higher incidence of postoperative complications was seen in lower extremity ILR patients (1.6%, 95%CI: 0.1%–4.8%, P < 0.001) than upper extremity ILR patients (0.9%, 95%CI: 0.1%–0.6%, P < 0.001), but neither significantly increased the risk of lymphedema (RR = 0.16, 95%CI: 0.01–4.26, P = 0.20). There was no correlation of lymphedema incidence rate with BMI (r = 0.115, P = 0.73), additional time added to a procedure (r = 0.159, P = 0.73), number of lymph nodes identified (r = −0.194, P = 0.54), and number of lymph nodes removed (r = 0.080, P = 0.80) CONCLUSIONS: Lymphedema is a common complication in cancer treatment that needs to be taken seriously. Immediate Lymphatic Reconstruction is an effective technique to restore lymphatic drainage at the time of the index procedure for both upper and lower extremities and will decrease the incidence of lymphedema. Plastic surgeons who perform axillary lymphadenectomy for breast cancer or inguinal lymphadenectomy for malignant melanoma or for vulvar cancer may increase a patient’s risk of lymphedema postoperation and should consider ILR to reduce this risk.