b'minimally invasive laparoscopic or robotic techniques,Risk-Reducing Surgery: Immediateor cervical VLN flaps (submental, supraclavicular).Lymphatic ReconstructionProximal (orthotopic) transfer to the axilla provides anImmediate lymphatic repair (ILR) involves anastomosis opportunity for lysis of scar bands that result fromof lymphatic vessels divided during axillary (or inguinal) axillary lymphadenectomy/radiation therapy which maylymphadenectomy and that are visualized by axillary be impeding arm range of motion or contributing 92toreverse lymphatic mapping (ARM) to adjacent veins the lymphedema by compression of the axillary within the surgical field. The technique has been used venous outflow, and the surgery may be combinedpredominantly in breast cancer and has demonstrated with microvascular postmastectomy breastreduced incidence of lymphedema development in reconstruction using an abdominal flap. There isseveral retrospective and prospective studies when evidence that performing LVB and VLNT synchronouslycompared with control patients or historical cohorts may provide a synergistic benefit due to their differentthat did not undergo the intervention 98 . ARM is mechanisms of action 93,94 . A randomized-controlledperformed prior to the lymphadenectomy using trial (RCT), systematic reviews and a meta-analysis, lymphazurin (isosulfan blue), ICG, or fluorescein as well as prospective and retrospective cohort andisothiocyanate (FITC), and lymphatic vessels visualized comparative studies, support the efficacy of VLNT can be spared when oncologically safe. Techniques for the treatment of lymphedema in reduction of limbinclude lymphovenous anastomosis using super volume as well as in episodes of cellulitis, functionalmicrosurgical techniques, and implantation of multiple improvement, and improved QoL, in patients withlymphatic vessels (lymphatic microsurgical preventing upper or lower extremity lymphedema 84,85,92,95 . healing approach, LYMPHA) or intima-to-intima Around half to three-quarters of patients in studiescoaptation technique 99,100 .where this outcome was reported were able to discontinue compression therapy postoperatively, Venoplasty and Stenting for Venous Lesions and subjective improvement was reported in aroundPresenting as Lymphedema (Including Ovarian85100% of patients. An RCT found that outcomesVein ablation)following VLNT were superior to conservativeVenous obstruction due to vessel occlusion or management alone 92 . narrowing can present as lymphedema in the affected Suction-assisted Lipectomy area. Venoplasty and stenting may be considered in patients with any symptomatic venous narrowing of In patients with severe fibroadipose soft-tissueaccepted anatomic areas such as the superior vena hypertrophy, tumescent suction-assisted lipectomycava (SVC), inferior vena cava (IVC), subclavian vein, (SAL) has been shown to be effective at reducing innominate vein, iliac veins, and ovarian veins.both the limb volume and incidence of postoperativeRelative contraindications include venous thoracic cellulitis in upper or lower extremity lymphedema outlet syndrome, bacteremia, and impaired renal in systematic reviews and meta-analyses, as well function in the setting of contrast agent use. Results as in prospective cohort and comparativehave shown primary patency of 75%, primary-assisted studies 28,84,96,97 . This procedure results in minimalpatency of 92%, and secondary patency of 93% inscarring and the complication rate is low; if patientsiliac vein stenting at 3 years post-procedure. Insertion wear compression garments lifelong, the recurrenceof an SVC stent has a long-term patency rate of 92%. rate is low over long-term follow-up. Patients who In summary, venoplasty and stenting are low-risk are compliant with wearing compression garmentsprocedures with high patency rates for up to 3 years continuously and have lymphedema with minimal and may provide symptomatic improvement in or no pitting edema are candidates for surgery. patients with lymphedema 101 .Selected patients may be candidates for stagedLVB and/or VLNT surgeries to improve long-termPleurodesis Shuntsoutcomes.In patients with chylothorax that are unresponsiveDirect Excisional Procedures to conservative management, one of the most used second-line treatments is pleurodesis. Pleurodesis is a Excisional techniques are indicated for patients procedure that induces intrapleural inflammation and with large volume advanced fibrotic disease. Thesefibrosis through a chemical irritant or mechanical include staged direct excision (including the modifiedabrasion to eliminate the pleural space. Povidone-Homans procedure), or, rarely, excision and skiniodine has been used in a handful of case reports and grafting (Charles procedure). Studies demonstratecase series to treat persistent chylothorax in neonates. improved patient-reported QoL and function, howeverIn reports with a defined protocol, povidone-iodine skin-grafting techniques are associated with highwas effective in up to 80% of selected cases of complication rates 84 . refractory neonatal chylothorax. Notable side effects | Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|26'