title: Do surgical interventions for limb lymphoedema reduce cellulitis attack frequency?
abstract: BACKGROUND
  Recurrent cellulitis is a frequent and challenging complication of lymphoedema. British Lymphology Society cellulitis guidelines state that decongestive lymphatic therapy reduces the frequency of cellulitis attacks, but do not mention the effect of surgical interventions. This systematic review aims to assess whether surgical interventions for lymphoedema reduce the frequency of attacks of cellulitis.
  
  
  METHODS
  Embase, Medline, and the Cochrane database were searched for relevant articles from database inception to January 2016. Four hundred and thirty-six abstracts were retrieved. Studies were included which contained quantitative data on cellulitis incidence before and after a surgical intervention. Two independent reviewers applied selection criteria, selecting 27 papers for full text review. Two were unavailable in the UK from any source.
  
  
  RESULTS
  A variety of surgical techniques were utilized in the 25 papers included: lymphaticovenous anastomosis, superficial-to-deep lymphaticolymphatic anastomosis, lymph node transfer, Charles procedure, muscle flap transfer, Homan's procedure, and subcutaneous tissue excision below skin flaps. Five studies combined techniques. One study compared the intervention to a control group (physical therapy). Cellulitis incidence was decreased following surgical intervention in 24/25 studies included. Eight had quantifiable reductions in cellulitis over a set follow-up period; in the other 16 preoperative incidence was not precisely defined.
  
  
  CONCLUSIONS
  Surgery appears effective at reducing cellulitis incidence in lymphoedema. However, high quality evidence from randomized controlled trials is lacking. Future research should concentrate on comparison with control groups, for example compression alone versus compression with surgical intervention, in patients with lymphoedema and greater than two attacks of cellulitis per year.
authors.affiliation: Oxford University Medical School, John Radcliffe Hospital, Medical Sciences Divison, Oxford University, Oxford, Oxfordshire, OX3 9DU.
authors.forename: Amy R
authors.initials: AR
authors.lastname: Sharkey
authors.affiliation: Oxford University Medical School, John Radcliffe Hospital, Medical Sciences Divison, Oxford University, Oxford, Oxfordshire, OX3 9DU.
authors.forename: Samuel W
authors.initials: SW
authors.lastname: King
authors.affiliation: Department of Plastic and Reconstructive Surgery, Nuffield Orthopaedic Centre, Oxford, OX3 7HE.|Oxford Lymphoedema Practice, Department of Plastic Surgery, The Manor Hospital, Beech Road, Oxford, OX3 7RP.
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Ramsden
authors.affiliation: Department of Plastic and Reconstructive Surgery, Nuffield Orthopaedic Centre, Oxford, OX3 7HE.|Oxford Lymphoedema Practice, Department of Plastic Surgery, The Manor Hospital, Beech Road, Oxford, OX3 7RP.|Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Oxford University, OX3 7HE.
authors.forename: Dominic
authors.initials: D
authors.lastname: Furniss
mesh_terms: D002481:Cellulitis / Q000453:epidemiology* / Q000209:etiology / Q000503:physiopathology; D005121:Extremities / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D015994:Incidence; D008209:Lymphedema / Q000150:complications / Q000601:surgery*; D008297:Male; D008866:Microsurgery / Q000379:methods*; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome
keywords: cellulitis; lymphaticovenous anastomosis; lymphedema lymphoedema; microsurgery