T Read, R Arora, G Velli, A Ho, M Cheng, L Watson
Prophylactic LVS was associated with a lower incidence of lymphedema following axillary and inguinal lymph node dissection. However, confidence in the estimated treatment effect is limited by the predominance of observational evidence, methodological heterogeneity, and possible publication bias, highlighting the need for adequately powered multicenter randomized trials.
BACKGROUND: Secondary lymphedema remains a frequent and debilitating complication of axillary and inguinal lymph node dissection within oncological settings. Prophylactic lymphovenous shunting (LVS) delivered as immediate lymphatic reconstruction (ILR) has emerged as a strategy to preserve lymphatic continuity and reduce postoperative lymphedema. This systematic review and meta-analysis evaluated the effectiveness of prophylactic LVS across oncologic indications.
METHODS: A comprehensive search of Medline (PubMed), Embase (Elsivier) and Cochrane Central databases identified comparative studies reporting lymphedema outcomes following prophylactic LVS performed at the time of nodal dissection. Seventeen studies met inclusion criteria, encompassing both upper- and lower-limb procedures. Primary outcome was incidence of clinically diagnosed lymphedema. A random-effects model was used to derive pooled effect estimates. Heterogeneity, subgroup analyses, and publication bias (including trim-and-fill adjustment) were assessed.
RESULTS: Across 2261 patients, prophylactic ILR was associated with a significant reduction in postoperative lymphedema (100/800 [12.5%] vs. 353/1461 [24.2%]); (pooled OR 0.27; 95% CI 0.17-0.42; p < 0.01). Between-study heterogeneity was moderate (I2 = 52.8%; Q = 35.47 p < 0.01). Subgroup analysis demonstrated no significant difference in treatment effect between upper- and lower-limb procedures (Qm = 0.47; p = 0.49). Trim-and-fill adjustment suggested potential small-study effects; however, the protective association persisted following imputation (adjusted OR 0.37; p < 0.0001). Overall, the direction of effect across studies was consistent.
CONCLUSIONS: Prophylactic LVS was associated with a lower incidence of lymphedema following axillary and inguinal lymph node dissection. However, confidence in the estimated treatment effect is limited by the predominance of observational evidence, methodological heterogeneity, and possible publication bias, highlighting the need for adequately powered multicenter randomized trials.