背景:淋巴水肿给现代社会带来了巨大的经济和社会负担。关于其风险因素的争议,诊断,治疗渗透到文献中。本研究的目的是在遵循Delphi方法的同时,评估专家对现有淋巴水肿文献的意见。
方法:2019年12月,美国静脉论坛成立了一个工作组,其任务是就当前淋巴水肿的诊断和治疗实践达成共识声明。工作组确定了一个专家小组。工作组随后编制了一份临床问题清单,危险因素,诊断和评估,和淋巴水肿的治疗。清单中列入了15个符合协商一致标准的问题。使用改进的Delphi方法,六个获得60%至80%选票的问题被列入第二轮分析名单。只要达成超过70%的协议,就会达成共识。
结果:专家小组达成共识,感染,慢性静脉疾病,手术是继发性淋巴水肿的危险因素。还达成了共识,即临床检查足以诊断淋巴水肿,并且所有患有慢性静脉功能不全(C3-C6)的患者均应作为淋巴水肿患者进行治疗。对于常规临床实践使用放射性核素淋巴闪烁显像作为强制性诊断工具,尚未达成共识。然而,小组就量化所有患者水肿的重要性达成共识(93.6%赞成).在治疗方面,达成共识,赞成定期使用压缩服装以减少淋巴水肿的进展(89.4%赞成,10.6%;平均得分为79),但使用Velcro器械作为压缩治疗的第一线并未达成共识(59.6%赞成vs40.4%反对;总分15分).与会者一致认为,序贯充气加压应被视为维持治疗阶段的辅助治疗(91.5%赞成vs.8.5%反对;平均得分为85),但在最初阶段就不那么好了(61.7%的支持率与38.3%反对;平均得分为27)。大多数小组同意手动淋巴引流应该是一种强制性的治疗方式(70.2%赞成),但是对于保守治疗失败的患者应考虑进行还原手术的建议,小组分为两半。
结论:这一共识过程表明,淋巴水肿专家同意大多数关于淋巴水肿危险因素的陈述,以及淋巴水肿患者的诊断检查。在与淋巴水肿的治疗有关的陈述上,缺乏共识。这一共识表明,即使在专家中,淋巴水肿护理的变异性也很高。未来淋巴水肿实践指南的开发者应该考虑这些信息,特别是在支持大多数专家不同意的实践模式的低级证据的情况下。
BACKGROUND: Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature. The goal of this study was to assess experts\' opinions on the available literature on lymphedema while following the Delphi methodology.
METHODS: In December of 2019, the American Venous Forum created a working group tasked to develop a consensus statement regarding current practices for the diagnosis and treatment of lymphedema. A panel of experts was identified by the working group. The working group then compiled a list of clinical questions, risk factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions that met the criteria for
consensus were included in the list. Using a modified Delphi methodology, six questions that received between 60% and 80% of the votes were included in the list for the second round of analysis.
Consensus was reached whenever >70% agreement was achieved.
RESULTS: The panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema. Consensus was also reached that clinical examination is adequate for diagnosing lymphedema and that all patients with chronic venous insufficiency (C3-C6) should be treated as lymphedema patients. No
consensus was reached regarding routine clinical practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool. However, the panel came to consensus regarding the importance of quantifying edema in all patients (93.6% in favor). In terms of treatment, consensus was reached favoring the regular use of compression garments to reduce lymphedema progression (89.4% in favor, 10.6% against; mean score of 79), but the use of Velcro devices as the first line of compression therapy did not reach consensus (59.6% in favor vs 40.4% against; total score of 15). There was agreement that sequential pneumatic compression should be considered as adjuvant therapy in the maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of 85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean score of 27). Most of the panel agreed that manual lymphatic drainage should be a mandatory treatment modality (70.2% in favor), but the panel was split in half regarding the proposal that reductive surgery should be considered for patients with failed conservative treatment.
CONCLUSIONS: This consensus process demonstrated that lymphedema experts agree on the majority of the statements related to risk factors for lymphedema, and the diagnostic workup for lymphedema patients. Less agreement was demonstrated on statements related to treatment of lymphedema. This
consensus suggests that variability in lymphedema care is high even among the experts. Developers of future practice
guidelines for lymphedema should consider this information, especially in cases of low-level evidence that supports practice patterns with which the majority of experts disagree.