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.     

Plastic surgery senior house officers in the UK and Ireland: academic background, publication rates and research plans.

Academic achievements by surgical trainees may vary according to the competitiveness of the subspecialty and desirability of the consultant post. Plastic and reconstructive surgery is a competitive specialty. In order to assess the level of achievement of current trainees, we investigated the academic qualifications, publication rates and future research plans of 100 senior house officers in plastic surgery working in units in the United Kingdom and Ireland. Selected results from our survey show that 30% had intercalated degrees, 6% had higher degrees, 58% of trainees had MRCS, 37% had previous plastic surgery experience and 57% had published (range 1-13). We believe this study provides interesting information concerning the current crop of plastic surgery trainees in the United Kingdom and Ireland. This survey may provide a benchmark for consultants to refer to when shortlisting for SHO posts. We also believe it will be of interest to those junior trainees hoping to pursue a career in plastic surgery.     

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.     

Delayed leech-borne infection with Aeromonas hydrophilia in escharotic flap wound.

Medicinal leeches (Hirudo medicinalis) are commonly used in plastic surgery for the salvage of congested flaps and replanted parts compromised by venous congestion. Infection associated with leech therapy is a documented complication of leech application, with reported incidences ranging from 2.4 to 20% [De Chalain TM. Exploring the use of the medicinal leech: a clinical risk-benefit analysis. J Reconstr Microsurg 1996;12(3):165-72.1]. We describe a case of delayed leech-borne infection, from the escharotic portion of a latissimus dorsi flap, which developed several days after stopping leech therapy for venous congestion in a reconstructed breast.     

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.     

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.     

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.     

LEECHES IN MEDICINE

Leeches have been used in medicine for blood-letting since ancient times. Leeching has varied in popularity over the years. It reached its zenith during the early decades of the 19th century with a gradual decline by the end of the century. Since the 1980s leeches have been introduced to remove blood where its accumulation may interfere with healing, particularly after plastic tissue-flap surgery. The history and current use of medicinal leeches in Australia is examined.     

Heparin-soaked gauze to salvage congested flaps: the poor man’s leech

An important and broad area of plastic surgery entails the cover of defects by pedicled or free flaps and the revascularisation of amputated parts of the body. Failure of perfusion in flaps and replants, due to venous congestion, presents a problem even to the most experienced surgeon. Many bleeding techniques have been used to relieve venous congestion after replantation and transplantation. The best known bleeding technique is probably the use of the medicinal leech. However, the use of leeches may present problems such as infection and significant blood loss. Instead, we advocate the use of heparin soaked gauzes on an intentionally de-epithelialized part of the congested flap. Over the last 12 months, we successfully applied this method in five cases. A full report on one of these cases is provided. Received: 1 December 1999 / Accepted: 1 February2000     

Thromboprophylaxis for radical prostatectomy: a comparative analysis of present practice between the USA, the UK, and Ireland

BACKGROUND: A clinical dilemma exists in the management of patients undergoing radical prostatectomy (RP) whereby measures taken to reduce the risk of thrombotic events may adversely affect efforts to limit blood loss. No consensus exists in the literature on the ideal management of thromboprophylaxis in these patients. Our aim is to examine and compare current thromboprophylactic policy and practice between the centres involved in performing RP. METHODS: A questionnaire was forwarded to all urology residency programmes in Ireland, the United Kingdom, and the United States, regarding their current practice with respect to thromboprophylaxis in RP. Completed questionnaire were returned by fax and the data entered into a computer database. RESULTS: An overall response rate of 60% was achieved. The questionnaires demonstrated a significant difference in clinical practice between Urologists in the United States and the United Kingdom. Just 24% of American Urologists use pharmacological thromboprophylaxis in contrast to 100% of British Urologists. There was no difference in the use of non-pharmacological thromboprophylaxis. Pharmacological thromboprophylaxis is mainly administered by units, mostly in the United Kingdom, doing fewer radical prostatectomies. CONCLUSIONS: While there have been studies advocating the use of pharmacological thromboprophylaxis in patients undergoing major pelvic surgery, there is no consensus on it is use in urological practice. This study has demonstrated significant differences in the management of thromboprophylaxis between the USA and the UK/Ireland. Units performing the largest number of radical prostatectomies, mostly in the USA, do not use pharmacological thromboprophylaxis and most do not use compression boots.     

Wiederherstellung der verbrannten Extremität durch Transplantation freier Lappenplastiken

Free tissue transplantation in burn reconstruction presents a major challenge to reconstructive surgeons. The results of a retrospective analysis of 68 free flaps in 55 patients are reported. This experience facilitated the establishment of reconstructive principles and a decision-making algorithm for primary and secondary reconstruction of burned extremities. Fourty-two free flaps were used for primary reconstruction. The indications were predominantly extremity salvage.The safety of the microsurgical procedures is correlated with the timing of the reconstruction. The failure rate of the free flaps was 24% in primary reconstruction. Due to an increased post-traumatic thrombogenicity, the period between 5 and 21 days had the highest risk of flap failure (40%).Twenty-six flaps were used for secondary reconstruction, with a success rate of 100%. Due to their elasticity, adipo- and fasciocutaneous flaps provide a useful option for the release of contractures. The large variability demonstrated by the use of 19 different types of free flaps showed that the reconstruction of burned extremities requires a reconstructive concept individualized to each patient as well as sophisticated microsurgical techniques. This clearly demonstrates the importance of a close link between primary burn treatment and reconstructive plastic surgery.     

Postoperative monitoring of free flaps in UK plastic surgery units

Monitoring free-tissue transfers in the postoperative period is valuable for detection of failing flaps. As well as conventional methods, a myriad of sophisticated techniques have been reported in the literature. Using a postal questionnaire, a survey was conducted to delineate current protocols employed in UK plastic surgery units. Data were received from 148 plastic surgeons in 51 units. All surgeons used clinical assessment, although there was significant disparity in the duration and frequency of postoperative monitoring. Adjuvant techniques such as laser Doppler flowmetry were routinely used by less than 20% of surgeons. We conclude that there is considerable variation in postoperative monitoring of free flaps, with significant clinical and resource implications. A protocol based on robust evidence is thus recommended.     

Perioperative management of trauma patients admitted on clopidogrel (Plavix). A survey of orthopaedic departments across the United Kingdom

BACKGROUND: Clopidogrel (Plavix) is an anti-platelet drug recommended as lifelong treatment by NICE for all patients following stroke, MI, and peripheral vascular disease. It is also indicated for short-term use following cardiac stent insertion. It irreversibly inhibits platelets for up to 7 days. Current recommendations are to stop treatment 7 days before elective surgery. Current evidence shows that delay to surgery more than 4 days in patients with hip fractures increases postoperative mortality. OBJECTIVES: To determine current practice of orthopaedic surgeons in their management of patients taking clopidogrel admitted following a hip fracture to trauma units in the UK with respect to its peri-operative withdrawal and subsequent timing of surgery. To perform a review of the available literature and produce a suggested protocol for the peri-operative management of this rapidly increasing cohort of patients. DESIGN: National postal survey. PARTICIPANTS: Orthopaedic consultants representing each unit receiving trauma patients in the United Kingdom. RESULTS: There was a 57% response rate (139/244 UK trauma units). 41% (56) stop clopidogrel and operate immediately, 11% (15) stop clopidogrel for between 5 and 10 days pre-operatively, 10% (14) stop clopidogrel for 10 days preoperatively, 19% (26) continue clopidogrel and operate immediately, 19% (26) have another protocol. 15% (20) have written departmental guidelines. 2%(3) quoted published evidence for their practice. CONCLUSIONS: This study demonstrates that there are a wide variety of practices, largely based on anecdotal evidence. Most units (85%) have no formal guidelines. There is evidence in the cardiac literature of increased intra-operative bleeding in patients operated on while taking clopidogrel. There is likely to be an exponential rise in such patients presenting to trauma units and further research is required to guide best practice. Following review of the literature we propose an interim protocol for the withdrawal and resumption of clopidogrel peri-operatively in patients with hip fractures.     

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.     

Comparing a mechanical device with medicinal leeches for treating venous congestion.

OBJECTIVE: To compare mechanical device therapy to medicinal leech therapy for treating venous congestion. STUDY DESIGN: Fasciocutaneous flaps of 9 x 7-cm (porcine model, n = 11) were elevated and the associated veins clamped for 15 hours. Device-treated flaps (n = 6) were treated with up to 3 devices/flap. Leech-treated flaps (n = 5) were treated with 75 leeches/flap (5 leeches/hour). Treatment evaluation parameters included: blood volume removed, skin color, surface perfusion, tissue oxygen tension, and endpoint histology. RESULTS: No significant differences were seen in blood volume removed, surface perfusion, and oxygen tension. However, significant differences were seen in skin color change over time. Histological assessment showed mild congestion in 5/5 leech-treated flaps and 2/6 device-treated flaps. CONCLUSION: Device therapy was comparable to leech therapy for decongesting a 9 x 7-cm flap over a 15-hour period. However, digital images and significant differences in skin color change over time demonstrate that device therapy promotes more global decongestion versus leech therapy.     

Acute postoperative infection with Aeromonas hydrophila after using medical leeches for treatment of venous congestion

Introduction

Venous convulsion after reconstructive microsurgery procedures is one major complication a surgeon has to deal with. Today, especially in the field of reconstructive microsurgery, medicinal leech therapy enjoys a renaissance. The potential risks such as infections associated with leech therapy are generally underestimated and not sufficiently discussed in literature.

Method/patients

We present five male patients with an average age of 47 years. All patients suffered from a trauma incident, which had to be treated as an emergency. Three patients showed, postoperatively, a venous congestion after the reconstructive procedures. Another two patients with flap reconstruction and flap training developed venous problems after 12 and 14 days. In all five cases, the indication was given to use medical leeches (Hirudo medicinalis). In all the patients, a local infection of the injured extremity could be regarded after beginning with the leech treatment. The treatment duration with medical leeches for postoperative venous congestion was an average of 6 days.

Results

The reconstructive procedures in all five cases were unfortunately unsuccessful as major local infections were observed. Microbiological analyses showed, in all cases, an infection with Aeromonas hydrophila.

Conclusion

We recommend making a considered indication for leech therapy, to diagnose wound infections early and to think about prophylactic antibiotics in patients with leech application.     

A simple method for the control of medicinal leeches

The medicinal leech, Hirudo medicinalis, has been widely used in the salvage of microvascular free flaps. Numerous publications have detailed the biology, use, benefits, and risks of leech therapy. One reported significant risk is the risk of leech movement or migration from the surgical site, possibly into body orifices or even deeper into the wound itself. The authors report a simple method of limiting the movement of medicinal leeches from the surgical site, namely, affixing one end of a surgical suture to the leech and tying the free end to a firm object or dressing. This simple method limits the potential range of movement of the leech and reduces the risk of leech migration to unwanted areas.     

A comparison of the academic impact of plastic surgery units in the United Kingdom and Ireland using bibliometric analysis

Academic output is just one aspect of a successful career as a plastic surgeon. However, for those with a strong interest in academia, the academic output of a department will likely be a key factor when deciding how to rank jobs. The aim of this study was to quantify and rank the academic output of plastic surgery units across the UK and Ireland. The Institute for Scientific Information (ISI) Web of Science Bibliometric analysis tool was used to collate cumulative (1950–2016), 10 year (2006–2016) and 3 years (2013–2015) research output data for plastic surgery units in the UK and Ireland. Sixty-six plastic surgery units were identified. Departments were ranked for each time period according to the number of papers produced, number of citations (Nc) and h-index (a measure of the impact of scientific output). The top 3 departments for number of papers in the last 10 years were The Royal Free Hospital, London (226) Broomfield Hospital, Chelmsford (218), and Morriston Hospital and Swansea (188). The top 3 for h-number were The Royal Free Hospital (21) Wythenshawe Hospital, Manchester (18) and Morriston Hospital (17). Academic output varies across plastic surgery units in the UK and Ireland. A number of departments have consistently maintained high academic outputs across the years and will be of interest to surgeons hoping to pursue a career in academia.     

Aeromonas hydrophila infections following use of medicinal leeches in replantation and flap surgery.

Aeromonas hydrophila infections are a recognized complication of postoperative leech application, and can occur with measurable frequency in populations of patients treated with leeches. We review 11 previously reported leech-related Aeromonas infections and analyze seven unreported cases. These infections range from minor wound complications to extensive tissue loss and sepsis. Often, these infections followed leech application to tissue with questionable arterial perfusion. Onset of clinical infection in these patients ranged from within 24 hours of leech application to 10 days or more after leech application. Late infections may represent bacterial invasion from colonized necrotic tissue. Based on these observations, we recommend that leech applications be restricted to tissue with arterial perfusion to minimize contamination of necrotic tissue. We also recommend that patients treated with leeches receive antibiotics effective against Aeromonas hydrophila before leech application. Patients treated with leeches and discharged with eschars or open wounds might benefit from oral antibiotic therapy until wound closure. These precautions may minimize or eliminate this complication of leech use.     

Use of selective decontamination of the digestive tract in United Kingdom intensive care units*

The use of selective decontamination of the digestive tract (SDD) remains controversial despite several large randomised‐controlled trials and meta‐analyses. A postal survey of intensive care units in the United Kingdom was conducted to document current use of SDD, and to identify factors influencing this practice. The response rate was 71%. The vast majority (182 units, 95%) do not use SDD mainly because practising clinicians do not believe it works or that there is not enough evidence (51%), and because of concerns about antibiotic resistance (47%). Of the 10 units using SDD, three apply it to all intubated patients and five do not use intravenous antibiotics in their protocol.