Bleeding and cupping

Bleeding and cupping have been used in medicine since ancient times in the treatment of fevers and local inflammatory disorders. Local bleeding, by 'wet cupping', was effected by a scarificator or by leeches. John Hunter recommended venesection in moderation but preferred leeches for local bleeding. Bleeding as an accepted therapeutic practice went out of vogue in the middle of the nineteenth century as a result of the introduction of modern scientific methods. Dry cupping and the use of leeches, as counter irritants, persisted until the middle of this century.     

Hirudo Medicinalis and the plastic surgeon.

Medicinal leech therapy is an ancient craft that dates back to ancient Egypt and the beginnings of civilisation. The popularity of Hirudo Medicinalis has varied throughout history, reaching such a peak in Europe in the early 19th century that supplies were exhausted. During the latter half of the 19th century, their use fell out of favour, as they did not fit in with the emerging concepts of modern medicine. Leeches have enjoyed a renaissance in the world of reconstructive microsurgery during recent years, and their first reported use in alleviating venous engorgement following flap surgery was reported in this journal [M Derganc, F Zdravic, Venous congestion of flaps treated by application of leeches, Br J Plast Surg 13 (1960) 187]. Contemporary plastic and reconstructive surgeons in units throughout the United Kingdom and Ireland continue to use leeches to aid salvage of failing flaps. We carried out a survey of all 62 plastic surgery units in the United Kingdom and the Republic of Ireland to assess the current extent of use, and to investigate current practice. We have shown that the majority of plastic surgery units in the UK and Ireland use leeches post-operatively and that the average number of patients requiring leech therapy was 10 cases per unit per year. Almost all units use antibiotic prophylaxis, but the type of antibiotic and combination used is variable. We outline current practice and suggest a protocol for the use of leeches. Whilst the use of leeches is widespread, the plastic surgery community has progressed little in defining indications for their use or in achieving an accepted protocol for their application in units throughout the UK and Ireland.     

The value of medical leeches in the treatment of class IIC ring avulsion injuries: report of 2 cases

Ring avulsion injuries pose a serious problem for the hand surgeon. According to the severity of the injury several classifications and their modifications have been proposed. In class IIC ring avulsion injuries arterial circulation is intact but only the venous supply is disrupted. Several therapeutic approaches have been suggested for these types of injuries. We present two class IIC cases that were treated successfully solely with leeches, with excellent results. Although the method is not a substitute for microvascular intervention leeches can be used when the clinical condition of a patient does not permit a lengthy surgery and if microvascular techniques fail or are thought to be pointless.     

Salvage of partial facial soft tissue avulsions with medicinal leeches

BACKGROUND: Medicinal leeches have been demonstrated to be extremely useful and safe in the salvage of venous outflow compromised tissue, particularly in digit replants and various forms of flaps. OBJECTIVE: To demonstrate the utility of medicinal leeches in the salvage of venous outflow-compromised traumatic soft tissue avulsions in key facial structures. METHODS: A retrospective review of 4 cases involving the external ear, nose, lip, and scalp in which apparent venous outflow compromise was present. Medicinal leeches were applied acutely in each of these 4 cases, salvaging each of the partially avulsed soft tissue segments. RESULTS: Complete or near complete salvage of each soft tissue segment after using medicinal leeches. CONCLUSIONS: Although it is unusual for a partial soft tissue avulsion of the face to require medicinal leech therapy, situations may occur in which there is adequate arterial inflow but inadequate venous outflow. In such cases, medicinal leeches may play a very important role in salvaging the soft tissue segment. This is particularly important in vital structures such as the ear, nose, lip, and eyelid in which acute or secondary reconstruction is complex. EBM RATING: C.     

Use of leeches in plastic and reconstructive surgery: a review

Leeches possess properties that make them uniquely able to assist with venous compromised tissue. Their saliva contains an anticoagulant and a histamine-like vasodilator that promote local bleeding, a local anesthetic, and hyaluronidase that promotes the local spread of the other leech salivary secretions into the wound/bite. In addition, active pharyngeal peristalsis further promotes the egress of venous blood. Resurgence in the use of leeches has been stimulated by Upton in the United States and Mahaffey in Europe. Currently, leeches are used at many microsurgical centers to provide critical venous outflow for compromised tissue replantations and transfers that might otherwise be unsalvageable. As the use of leeches becomes more widespread, knowledge of leech biology and physiology is important. This review reports on Hirudo medicinalis, the species used most often medically in Europe and the United States.     

Postprandial Aeromonas hydrophila cultures and antibiotic levels of enteric aspirates from medicinal leeches applied to patients receiving antibiotics.

Increasing use of medicinal leeches has been accompanied by increasing numbers of reports of Aeromonas hydrophila infections after leech application on or near damaged tissue. We examined the enteric contents of postprandial leeches after their application to patients receiving antibiotics. We found measurable levels of antibiotic in the leech enteric contents, and in leeches applied to patients receiving an antibiotic effective against Aeromonas hydrophila, there was a significant decrease in positive Aeromonas enteric cultures. Suppression of leech enteric bacteria by antibiotic administration to the patient may be an effective strategy to prevent invasive infection by Aeromonas hydrophila as well as bacterial colonization of devitalized tissue that could be the source of late infection. Clinical studies will be required to clarify whether suppression of leech enteric flora results in a decrease in infections associated with leech use.     

Leech-borne Serratia marcescens infection following complex hand injury.

Leeches are commonly used in the postoperative course of plastic surgical operations where there is venous congestion in a pedicled or free flap. They provide a temporary relief to venous engorgement whilst venous drainage is re-established. It is known that leeches can carry Aeromonas hydrophila infection, and a second or third generation cephalosporin antibiotic has traditionally been given as prophylaxis against infection. We report a new observation that leeches can carry Serratia marcescens and give rise to clinically significant infection. The implication for prophylaxis and treatment of leech-associated cellulitis is discussed.     

活体水蛭吸血疗法临床应用8例

目的总结并探讨应用活体水蛭吸血疗法救治皮瓣静脉淤血的临床疗效。方法对进行性加重的皮瓣静脉淤血,采用活体水蛭置于皮瓣表面吸吮血液,待皮瓣血运明显改善后结束治疗。结果1991年1月至2006年12月,临床应用8例,除1例皮瓣远端边缘部分出现小面积坏死外,其余7例均取得良好的治疗效果。结论活体水蛭吸血疗法是一种简单、直接、较为廉价的救治皮瓣静脉淤血的方法。     

Clinical and scientific considerations in leech therapy for the management of acute venous congestion: an updated review

Any surgical intervention that involves the manipulation of veins, large or small, carries the risk of acute venous congestion. Venous congestion is the product of an imbalance between arterial inflow and venous outflow, and results in the stasis of blood in the tissues that are normally drained by the affected veins. The resultant lack of tissue perfusion causes hypoxia, acidosis, and arterial thrombi formation, which can potentially progress to tissue necrosis and wet gangrene. In the past several decades, the use of leeches (Hirudo medicinalis) has been rediscovered as an effective method of relieving acute venous congestion. This updated review of leech therapy focuses on the use of medicinal leeches in a variety of clinical conditions characterized by acute venous congestion, and points out the experimental use of leeches in other pathological entities. A discussion of the recent scientific findings that explain the possible mechanisms of action of leech therapy is also provided.     

Antibiotic sensitivities of Aeromonas hydrophila cultured from medicinal leeches

Increased use of medicinal leeches (Hirudo medicinalis) for the treatment of venous congestion in flaps and replanted parts has coincided with reports of soft tissue infections following leech application. We cultured the gullets of 20 medicinal leeches to re-examine the antibiotic sensitivities of Aeromonas hydrophila, the leech enteric organism associated with reported infections. These isolates reflected reported resistance to penicillin and first generation cephalosporins as well as sensitivity to gentamicin, tetracycline and chloramphenicol. Additionally, the cultures were sensitive to cefamandol, cefoxitin and two third generation cephalosporins (cefoperazone and cefotaxime). These findings suggest that cefamandol, cefoxitin and some third generation cephalosporins may have a role as perioperative antibiotics in replantation and flap surgery. These antibiotics might provide prophylaxis against Aeromonas hydrophila infection when leech use is required.     

The use of leeches for treatment of venous congestion of the nipple following breast surgery

The medicinal leech,Hirudo medicinalis, played a central role in the evolution of medieval and folk medicine. Today, for the first time in history, the leech actually has a real and valuable purpose in medicine as a useful adjunct for the plastic surgeon: It provides relief of venous congestions. For over 2000 years, leeches were needlessly applied for a multitude of maladies as an adjunct to blood-letting. Their use in Europe peaked between 1830 and 1850, however, shortages led to a subsequent decline in leech application. Today there is a real clinical use for leeches which had led to a resurgence in their use in plastic surgery. Plastic surgeons use leeches in microsurgery to salvage congested flaps, whose viability is uncertain due to venous congestion. We present our experience with two patients where leeches were used to treat isolated venous engorgement of the nipple following breast surgery. Leech therapy is painless, well tolerated, and does not result in significant scarring. Prompt initiation of treatment is mandatory and produces dramatic resolution of venous congestion.     

Johann Friedrich Dieffenbach: successful use of leeches in plastic surgery in the 1820s.

Johann Friedrich Dieffenbach (1792-1847) regularly and successfully utilised leeches in sophisticated plastic surgery in Berlin in the 1820s and 1830s, well before anaesthesia, antisepsis and antibiotics. Inexplicably, it took nearly another 150 years before the use of leeches in this context was revived.     

Aeromonas species isolated from medicinal leeches

Aeromonas hydrophila infections are a recognized complication of the use of medicinal leeches. The authors performed an experiment designed to find a safe and practical way to sterilize the leech gut of pathogenic organisms. Leeches were incubated for a 12-hour period in solutions of antibiotic effective against A. hydrophila. The incubations in the antibiotic solutions failed to eradicate pathogenic bacteria from the gut of the leeches. The authors examined cultures of bacteria isolated from the guts of the commonly used Hirudo medicinalis (European leech) and found a wide variety of pathogenic organisms. A. hydrophila is widely believed to be the most common enteric pathogen, but the authors found A. sobria more frequently in their experiment. They also cultured the guts of the leech H. michaelseni recently used clinically in South Africa. A. caviae was the most common pathogen encountered in these leeches. A. caviae and A. sobria cause a spectra of disease similar to A. hydrophila. The authors endorse the current recommendation that all patients who have leech therapy for congested flaps or replants receive broad-spectrum prophylactic antibiotics. This appears to be the safest and simplest way to prevent leech-related infections.     

Aeromonas hydrophila infection complicating digital replantation and revascularization

Two cases of thumb replantation and one of finger revascularization complicated by Aeromonas hydrophila infection are reported. Two digits were lost because of infection in soft tissue and osteomyelitis. One thumb had extensive necrosis. In all cases the infection was difficult to eradicate, probably because of ischemia. All three patients sustained their injuries while cutting meat or fish. These infection sources have not been previously reported. Note is made of Aeromonas hydrophila in medicinal leeches that are used in microvascular surgery and the potential for iatrogenic infection.     

Digit replantation applying the leech Hirudo medicinalis

Digits that were formerly assessed as nonreplantable may now be replanted with the help of the leech Hirudo medicinalis. The early experience with a series of patients who had relative contraindications for replantation is reported. In each case, venous repair was either marginal or technically impossible. Postoperative venous congestion developed following replantation and was treated with the application of medicinal leeches. Patient acceptance was high, and no infections developed. No patient required transfusion. The authors conclude that the use of medicinal leeches shows promise as a safe and effective method of providing temporary venous drainage in replanted digits.     

Aeromonas hydrophila infection complicating digital replantation and revascularization

Two cases of thumb replantation and one of finger revascularization complicated by Aeromonas hydrophila infection are reported. Two digits were lost because of infection in soft tissue and osteomyelitis. One thumb had extensive necrosis. In all cases the infection was difficult to eradicate, probably because of ischemia. All three patients sustained their injuries while cutting meat or fish. These infection sources have not been previously reported. Note is made of Aeromonas hydrophila in medicinal leeches that are used in microvascular surgery and the potential for iatrogenic infection.     

Medicinal leeches and the microsurgeon: a four-year study, clinical series and risk benefit review

Background: There are case reports and small series in the literature relating to the use of medicinal leeches by plastic surgeons; however, larger series from individual units are rare. The aim of this article is to present a comprehensive 4‐year case series of the use of medicinal leeches, discuss the current evidence regarding indications, risks, and benefits and highlight the recent updates regarding leech speciation. Methods: Patients prescribed leeches in a 4‐year period (July 2004–2008) were collated from hospital pharmacy records (N = 35). The number of leeches used, demographic, clinical, and microbiological details were retrospectively analyzed. Results: Thirty‐five patients were treated with leeches. The age range was 2 to 98 years (mean = 49.3). Leeches were most commonly used for venous congestion in pedicled flaps and replantations. Blood transfusions were necessary in 12 cases (34%) [mean = 2.8 units, range 2–5 units]. Our infection rate was 20% (7/35) including five infections with Aeromonas spp. (14.2%). The proportion of patients becoming infected after leech therapy was significantly greater in the group of patients that did not receive prophylactic antibiotic treatment (Fisher's Exact test P = 0.0005). In total, 14 cases (40%) were salvaged in entirety, in 7 cases 80% or more, in 2 cases 50 to 79%, and in 1 case less than 50% of the tissues were salvaged. In 11 cases (31%), the tissues were totally lost. Conclusion: Our study highlights both the benefits and the risks to patients in selected clinical situations and also the potential risks. The routine use of antibiotic prophylaxis is supported. In view of the emerging evidence that Hirudo verbana are now used as standard leech therapy, and the primary pathogen is Aeromonas veronii, until a large prospective multicenter study is published, large series of patients treated with leeches should be reported. © 2011 Wiley‐Liss, Inc. Microsurgery, 2011.     

Successful treatment of venous congestion in free skin flaps using medical leeches

Of 74 patients with extensive skin loss of the upper and lower extremities who were treated with free skin flaps, 20 patients presented with venous insufficiency within the immediate 6 to 12 hours following surgery. In 17 of these patients, the venous congestion after free tissue transfer was successfully treated with medical leeches. The remaining three skin flaps did not survive, despite leeching, as well as exploration and revision of the venous anastomoses. The results from this small number of patients with free skin tissue transfers are encouraging, suggesting that in the presence of venous congestion, the use of medicinal leeches is a desirable modality of treatment. © 1994 Wiley-Liss, Inc.