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      Efficacy and safety assessment of lymphovenous anastomosis in patients with primary and secondary lymphoedema: A systematic review of prospective evidence

      , BSc, MSc , 1 , , AKC, MA 1 , 2


      John Wiley & Sons, Inc.

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          Lymphoedema is a chronic, debilitating condition caused by an affected lymphatic system. Supermicrosurgical techniques like lymphovenous anastomosis (LVA) have gained popularity because of its minimal invasiveness, better aesthetic outcome, and lower costs in comparison to physical medicine. This systematic review aims to evaluate the clinical effectiveness and safety of LVA in comparison to conservative or other surgical treatments for primary or secondary lymphoedema patients.

          Materials and Methods

          A systematic literature search was performed in four databases in December 2017. We applied a methodological framework based on the HTA Core Model®. According to the grading of recommendations, assessment, development, and evaluation (GRADE) scheme, we synthesized the data on each selected outcome category. The studies were systematically assessed for risk of bias (RoB) using the Risk of Bias Assessment tool for Non‐randomized controlled studies (RoBANS) and the Institute of Health Economics (IHE) Risk of Bias checklist for case series.


          A total of 629 citations were identified and five studies were assessed eligible for final inclusion (one non‐randomized controlled trial and four prospective single‐arm studies). Across the studies, 217 patients were enrolled. All studies showed a moderate to high RoB. The strength of evidence for the effectiveness and safety of LVA is “very low.” Due to the methodological shortcomings of the available evidence, no conclusions can be made about the effectiveness of the procedure.


          LVA might be a safe technique for patients with primary and secondary lymphoedema—particularly because no serious complications were reported. Furthermore, LVA may have a role in the prevention of lymphoedema.

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          Most cited references 28

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          Testing a tool for assessing the risk of bias for nonrandomized studies showed moderate reliability and promising validity.

          To develop and validate a new risk-of-bias tool for nonrandomized studies (NRSs). We developed the Risk of Bias Assessment Tool for Nonrandomized Studies (RoBANS). A validation process with 39 NRSs examined the reliability (interrater agreement), validity (the degree of correlation between the overall assessments of RoBANS and Methodological Index for Nonrandomized Studies [MINORS], obtained by plotting the overall risk of bias relative to effect size and funding source), face validity with eight experts, and completion time for the RoBANS approach. RoBANS contains six domains: the selection of participants, confounding variables, the measurement of exposure, the blinding of the outcome assessments, incomplete outcome data, and selective outcome reporting. The interrater agreement of the RoBANS tool except the measurement of exposure and selective outcome reporting domains ranged from fair to substantial. There was a moderate correlation between the overall risks of bias determined using RoBANS and MINORS. The observed differences in effect sizes and funding sources among the assessed studies were not correlated with the overall risk of bias in these studies. The mean time required to complete RoBANS was approximately 10 min. The external experts who were interviewed evaluated RoBANS as a "fair" assessment tool. RoBANS shows moderate reliability, promising feasibility, and validity. The further refinement of this tool and larger validation studies are required. Copyright © 2013 Elsevier Inc. All rights reserved.
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            A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema.

            The authors prospectively evaluated the efficacy of lymphovenous bypass in patients with lymphedema secondary to cancer treatment.
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              Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities.

              Over the last eight years, the authors analyzed obstructive lymphedema of a unilateral upper extremity in a total of 27 females, comparing the use of supramicrosurgical lymphaticovenule anastomoses and/or conservative treatment. The most common cause of edema was mastectomy, with or without subsequent radiation therapy for breast cancer. As an objective assessment of the extent of edema, the circumferences of the affected and opposite normal forearms were measured at 10 cm below the olecranon of the arm. Twelve of these patients received continual bandaging. In these patients, the average excess circumference of the affected arm was 6.4 cm over that of the normal forearm; the average duration of edema before treatment was 3.5 years; the average period for conservative treatment was 10.6 months; and the average decrease in circumference was 0.8 cm (11.7 percent of the preoperative excess). Twelve patients underwent surgery and postoperative continual bandaging. In these patients, the average excess circumference was 8.9 cm; the average duration of edema before surgery was 8.2 years; the average follow-up after surgery was 2.2 years; and the average decrease in circumference was 4.1 cm (47.3 percent of the preoperative excess). These results indicated that supermicrolymphaticovenular anastomoses with postoperative bandaging have a valuable place in the treatment of obstructive lymphedema.

                Author and article information

                John Wiley & Sons, Inc. (Hoboken, USA )
                30 September 2019
                November 2019
                : 39
                : 8 ( doiID: 10.1002/micr.v39.8 )
                : 763-772
                [ 1 ] Ludwig Boltzmann Institute for Health Technology Assessment Vienna Austria
                [ 2 ] Faculty of Philosophy and Education University of Vienna Vienna Austria
                Author notes
                [* ] Correspondence

                Katharina Rosian, Ludwig Boltzmann Institute for Health Technology Assessment, Garnisongasse 7/20, 1090 Vienna, Austria.

                Email: katharina.rosian@

                © 2019 The Authors. Microsurgery published by Wiley Periodicals, Inc.

                This is an open access article under the terms of the License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                Page count
                Figures: 2, Tables: 4, Pages: 10, Words: 5826
                Review Article
                Review Article
                Custom metadata
                November 2019
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.7.2 mode:remove_FC converted:05.12.2019


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