A systematic review of selection criteria for extirpative and combined surgical procedures in lower extremity...

Advanced lower extremity lymphedema is difficult to manage and can lead to significant functional impairment and diminished quality of life. Extirpative (also known as excisional and debulking) surgical procedures offer meaningful volume reduction for patients with advanced disease refractory to conservative management. The objective of this systematic review was to identify the clinical and imaging criteria used to determine candidacy for excisional surgery (ie, Charles and modified Homan procedures) in adults with lower extremity lymphedema and to report the surgical outcomes observed across the included studies.

A systematic search of PubMed, Embase, and Cochrane Library was conducted by an expert medical librarian. The search yielded 3916 articles. Inclusion criteria involved randomized controlled trials, cohort studies, and case series that reported on excisional surgical procedures for adults with lower extremity lymphedema and described clinical or imaging criteria for surgical candidacy. Studies that did not involve patients with lower extremity lymphedema were excluded. Screening, full-text review, and data extraction were performed using Covidence software (Veritas Health Innovation) with standardized data extraction templates. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Five studies were included in this systematic review. There was a total of 933 patients across all studies. The five included studies were one systematic review, three retrospective cohorts or case series, and one small case series. Five clinical criteria for surgical candidacy were identified in this review: failure of conservative management, advanced clinical staging (International Society of Lymphology III or equivalent), functional impairment, skin changes, and recurrent infections. No imaging was used to determine surgical candidacy for excisional surgery alone in lower extremity lymphedema. Quality of life was not formally measured with validated instruments in any study.

This systematic review reveals a fundamental absence of validated, evidence-based selection criteria for extirpative surgery in lower extremity lymphedema. The current selection process is entirely surgeon dependent, institution specific, and nonstandardized. This represents a critical barrier to the development of clinical guidelines and equitable patient care. No existing evidence supports the superiority of any particular set of selection criteria over another.