Surgical options for lymphedema after gynecological cancer treatment: current trends and advances.

Lower leg lymphedema is an important complication after gynecological treatment that can severely affect the quality of life of long-term survivors of these malignancies. As a chronic and progressive disease, affected patients will require life-long therapy centered on compression. Although conventional compressive treatments can be effective, they are extremely burdensome and time-consuming for most patients and adherence is challenging. With advances in the field of reconstructive microsurgery, new procedures have been developed in the past decades to help these patients in their continuous care and have been offered at many oncological centers around the world as a first line of treatment. We performed a PubMed search using the Mesh terms 'Lymphedema/surgery' and 'Lower extremity' yielding a total of 508 articles. Of these, 35 articles were included for analysis. Articles that failed to provide a comprehensive analysis of outcomes following surgical treatment, studies examining treatment for upper limb lymphedema, primary lymphedema, or lower extremity lymphedema resulting from non-gynecologic etiologies, and studies that failed to have a minimum of 6 months follow-up were excluded. A comprehensive review of these 35 articles including over 1200 patients demonstrated large variability on the outcomes reported; however, an overall benefit from these procedures was found. Surgical options including lymphovenous anastomosis, vascularized lymph node transfers, and excisional procedures can be performed in patients with lower leg lymphedema, depending on staging and findings in indocyanine green lymphography. Surgical treatment of lymphedema is an effective option that can improve symptoms and quality of life of patients suffering from lymphedema following gynecologic cancers.

Use of fluorescence imaging during lymphatic surgery: A Delphi survey of experts worldwide.

BACKGROUND: Fluorescence imaging with indocyanine green is increasingly used during lymphedema patient management. However, to date, no guidelines exist on when it should and should not be used or how it should be performed. Our objective was to have an international panel of experts identify areas of consensus and nonconsensus in current attitudes and practices in fluorescence imaging with indocyanine green use during lymphedema surgery patient management. METHODS: A 2-round Delphi study was conducted involving 18 experts in the use of fluorescence imaging during lymphatic surgery, all asked to vote on 49 statements on patient preparation and contraindications (n = 7 statements), indocyanine green dosing and administration (n = 10), fluorescence imaging uses and potential advantages (n = 16), and potential disadvantages and training needs (n = 16). RESULTS: Consensus ultimately was reached on 40/49 statements, including consistent consensus regarding the value of fluorescence imaging with indocyanine green in almost all facets of lymphedema patient management, including early detection, assessing disease extent, preoperative work-up, surgical planning, intraoperative guidance, monitoring short- and longer-term outcomes, quality control, and resident training. All experts felt it was very safe, while 94% felt it should be part of routine care and that indocyanine green was superior to colored dyes and ultrasound. Nonetheless, there also was consensus that limited high-quality evidence remains a barrier to its widespread use and that patients should still be provided with specific information and asked to sign specific consent for both fluorescence imaging and indocyanine green. CONCLUSION: Fluorescence imaging with or without indocyanine green appears to have several roles in lymphedema prevention, diagnosis, assessment, and treatment.