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

In 30 seconds

This systematic review examined clinical and imaging criteria used to select adults with lower extremity lymphedema for excisional surgery, including Charles and modified Homan procedures, and summarized reported outcomes. Five studies covering 933 patients met the inclusion criteria. Selection commonly involved failure of conservative management, advanced disease stage, functional impairment, skin changes, or recurrent infections; no imaging criteria were used for excisional surgery alone. None of the studies formally assessed quality of life with validated instruments. The review found no validated, evidence-based selection criteria and no evidence that one set of criteria is superior.

Key findings

• Five included studies covered 933 patients; the evidence comprised one systematic review, three retrospective cohorts or case series, and one small case series.
• Five clinical selection criteria were identified: failed conservative management, advanced staging, functional impairment, skin changes, and recurrent infections.
• No imaging was used to determine candidacy for excisional surgery alone, and no study formally measured quality of life with validated instruments.
• The review found no validated selection criteria and no evidence that any particular criteria set is superior.

Why it matters

Selection for extirpative surgery appears to vary by surgeon and institution rather than follow validated, standardized criteria. This limits the basis for consistent clinical guidance and equitable patient selection. The absence of validated quality-of-life measurement also leaves uncertainty about how reported surgical outcomes reflect patients’ lived experience.

What to keep in mind

The review included only five studies, with much of the evidence from retrospective cohorts or case series. Validated quality-of-life outcomes were not reported in any included study.