The Lymphatic System—A Surgeon’s Point of View
Round 1
Reviewer 1 Report
This article is an overview of the diagnosis and treatment of lymphedema, emphasizing the importance of making informed clinical decisions based on a wide variety of imaging techniques available. The evolution of lymphedema surgery from debulking to physiologic procedures has been proven effective, and a combination of both approaches can result in a synergistic benefit for patients. The surgical procedures should be performed by experienced surgeons to reduce the risks associated with them.
I agree with the authors that review to summarize lymphedema management from a surgeon’s point of view, although it is crucial to note that complex decongestive therapy is the primary treatment, and surgical procedures are only considered when conservative treatments are no longer effective.
Author Response
Thank you for your feedback
The proposed alterations were done as following:
Point 1: "It is crucial to note that complex decongestive therapy is the primary treatment, and surgical procedures are only considered when conservative treatments are no longer effective."
It was added on the introduction section: "Nonsurgical treatment remains the cornerstone of early-stage management, with the aim of increasing interstitial pressure and decreasing capillary filtration, preventing the progression to clinical lymphedema. There is also some evidence that conservative treatment, widely accepted as the universal first-line therapy for extremity lymphedema, provides benefits in volume reduction for mild lymphedema.However, this approach does not address the underlying lymphatic dysfunction or pathophysiology of disease progression[3]. In cases where nonsurgical management is no longer effective, surgical options are considered, including debulking and physiologic procedures."
Reviewer 2 Report
This is an excellent review of the different diagnostic options for lymphedema and how it is treated surgically. It is well-written and thorough. While it is more of a review rater than a study, I think it still provides a necessary outlet for discussion on the treatment algorithms for lymphedema.
Author Response
Thank you for your feedback. I hope it proves useful to our colleagues.
Reviewer 3 Report
This paper is a very well-researched review with a primary focus on surgical approaches in lymphedema treatment.There is a lack of evidence in many surgical treatments for lymphedema, including LVA, making it difficult to provide an aggressive roadmap.
Comment 1
Conservative treatment has a longer history than surgical treatment, and the importance of conservative treatment should be taken into account in the “Introduction” section, as there is no evidence that surgical treatment modalities outperform conservative treatment.
Comment 2
LVA has been shown to be effective in early cases of lymphedema. However, even advanced cases can benefit from circumferential reduction. The smooth muscle function of the lymphatic vessels may play a significant role in these results, and author should investigate whether the results of RI, ICG, or other tests can predict the outcome of LVA.
Author Response
Thank you for your feedback.
The proposed alterations were done as following.
Point 1
It was added this information on the introduction section: "Nonsurgical treatment remains the cornerstone of early-stage management, with the aim of increasing interstitial pressure and decreasing capillary filtration, preventing the progression to clinical lymphedema. There is also some evidence that conservative treatment may provide benefits in volume reduction for mild lymphedema being widely accepted as the universal first-line therapy for extremity lymphedema. However, this approach does not address the underlying lymphatic dysfunction or pathophysiology of disease progression [3]. In cases where nonsurgical management is no longer effective, surgical options are considered, including debulking and physiologic procedures. "
Point 2
It was added on LVA section: "To achieve successful long-term LVA, certain principles must be followed. Candidates for LVA must have functional or at least draining lymphatic vessels and a venule in proximity without reflux. As described before, there are many imaging modalities available to evaluate the functional status of lymphatics and consequently to predict the outcome of LVA. The most used is ICG-L. Since all of the lymphatic pathways do not deteriorate concurrently or to the same extent, early stage patients are more likely to have functional lymphatics in superficial distribution that are easily visualized by ICG -L. On the other hand, patients in advanced stages may benefit from methods such as MRL or SPECT/CT to reveal deeper functional lymphatics. Therefore, the integration of different imaging modalities (ex: ICG-L and MRL) increases the reliability of the preoperative localization of functional lymphatics and may predict the outcome of LVA."
