title: Surgical procedures in lymphedema management.
abstract: OBJECTIVE
  Lymphedema has a high incidence and various causes. It reduces patients' quality of life and productivity and currently lacks a cure. Management is based on lifelong physical therapies. Many surgical procedures have been proposed for lymphedema without significant acceptance. This study evaluates surgical procedures aimed at the management of lymphedema and highlights present evidence.
  
  
  METHODS
  Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Grading of Recommendations Assessment, Development and Evaluation consensus, a systematic literature search (MEDLINE and The Cochrane Library) was performed to identify studies evaluating treatment outcomes after lymphedema surgery. The authors evaluated all articles found with the keywords "lymphedema" and "surgery," including experimental studies in animals. Cross referencing was made. Next, a protocol was created to assess the degree of quality of publications in this field. An overview of the complete medical literature was performed. Thereafter, publications meeting inclusion criteria were attributed a score according to the assessment protocol. This allowed an overview of the scientific quality of all surgical procedures for lymphedema.
  
  
  RESULTS
  A total of 108 article texts were read and 70 publications included in this study according to predefined criteria. Lymphedema operative procedures were classified according to type. The outcomes highlighted the importance of individual patient analysis, as most interventions are not sufficiently studied to sustain clinical recommendations.
  
  
  CONCLUSIONS
  Risk factors for acquired lymphedema, such as lymph node excision and radiation therapy, are well identified and should allow primary prevention. Improved diagnosis, classification, standardized volume measurement, staging, and follow-up of lymphedema patients can facilitate their management and allow valid retrospective studies. Currently, there is no evidence of any treatment yielding high long-term cure rates. Therefore, lymphedema management must be based on interdisciplinary approaches, with curative or palliative therapy options discussed openly with the patient. Therapeutic plans should not exclude surgery. Nevertheless, additional studies are recommended to prove the validity of some surgical approaches.
authors.affiliation: Department of Plastic, Hand and Reconstructive Surgery (Director: Univ.-Prof. Dr. med. Peter M. Vogt), Hannover Medical School, Hannover, Germany. Electronic address: hadamitzky.catarina@mh-hannover.de.
authors.forename: Catarina
authors.initials: C
authors.lastname: Hadamitzky
authors.affiliation: Institute of Immunomorphology, Hannover Medical School, Hannover, Germany.
authors.forename: Reinhard
authors.initials: R
authors.lastname: Pabst
authors.affiliation: Dermatology Department, St George's Hospital, London, United Kingdom.
authors.forename: Kristiana
authors.initials: K
authors.lastname: Gordon
authors.affiliation: Department of Plastic, Hand and Reconstructive Surgery (Director: Univ.-Prof. Dr. med. Peter M. Vogt), Hannover Medical School, Hannover, Germany.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Vogt