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.     

Nonarterialized Venous Replantation of Part of Amputated Thumb—A Case Report and Review of the Literature

Since the first successful replantation of a human thumb reported by Komatsu and Tamai in 1968, thousands of severed digits and body parts have been successfully salvaged. Restoration of anatomic form and function are the goals of replantation after traumatic tissue amputation. Regardless of anatomic location, methods include microsurgical replantation and nonmicrosurgical replantation, such as composite graft techniques. Numerous techniques to maximize tissue survival after revascularization have been described, including “pocket procedures” to salvage composite grafts, interposition vein grafts, and medicinal leeches to name a few. Artery-to-venous anastomoses have been performed with successful “arterialization” of the distal venous system in fingertip replantation. Although there is documented survival of free venous cutaneous flaps, to our knowledge this is the first report of a replanted composite body part (bone, tendon, soft tissues, and skin) utilizing exclusively multiple, microvascular, nonarterialized venous–venous anastomoses. We present a patient with an isolated band saw fillet amputation to the back of the thumb at the metacarpal–phalangeal joint region, resulting in a composite graft composed of bone, tendon, soft tissue, and skin. The hand wound provided no viable regional arterial inflow source, but there were multiple good caliber superficial veins present. The amputated tissues were replanted and revascularized by using only venous blood flow. The replanted part survival was 100% with excellent function of the digit. We conclude that a hand composite body part involving bone, tendon, soft tissues, and skin can survive replantation with a strict venous blood supply if sufficient good caliber, microvascular, venous–venous anastomoses are performed, granted that arterial inflow options are not available. This is an isolated case, yet introduces a new way of thinking regarding tissue replantation.     

Microsurgical replantation of a partial ear, with leech therapy.

Ear reconstruction is very difficult to perform and often results in a devastating deformity. The use of microsurgical replantation techniques has allowed very favorable aesthetic results. The authors report a case of partial ear replantation without venous repair with the use of medicinal leeches to decompress the acute venous congestion that occurred during postoperative care. Medicinal leech therapy can be very useful in partial ear replantation in cases with no venous repair.     

Successful microvascular replantation of a completely amputated ear

A case of successful microvascular replantation of a traumatically amputated ear is presented. The postoperative course was complicated by venous thrombosis requiring the use of medicinal leeches and systemic heparinization for salvage. This is the tenth successful microvascular ear replantation reported in the literature. © 1993 Wiley-Liss Inc.     

Microsurgical replantation of the external ear

Cosmetically, the optimal management of the amputated external ear is microsurgical replantation. Although technically demanding, replantation is possible by the experienced surgeon. Success frequently requires the use of vein grafts, heparinization, and the alleviation of venous congestion with medicinal leeches or frequent stab wounds.     

Microsurgical replantation of a partial helix of the ear

Microsurgical ear replantation is a significant challenge because vessel sizes are diminutive. Furthermore, as ear vessels are larger in the medial portion than in the lateral portion, microsurgical replantation of a replant including only the helix is extremely difficult. The authors replanted a partial helix of the ear using a single arterial anastomosis. As no suitable veins could be identified, medicinal leech therapy and systemic heparinization were used to achieve venous drainage. The replanted helix survived completely and the cosmetic result was excellent. Microsurgical replantation should be considered the treatment of choice in helix amputation cases, even though amount of replant is small. © 2009 Wiley‐Liss, Inc. Microsurgery 2009.     

Penile replantation using the leech Hirudo medicinalis

A 37-year-old chronic schizophrenic man underwent penile replantation after complete autoamputation using a kitchen knife. We report the first case of using medicinal leeches to salvage a penile replant after the development of postoperative venous congestion.     

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.     

Transitional cell carcinoma of the bladder metastatic to the penis

Penile amputation is a rare urologic trauma for which immediate surgical replantation is indicated. Microsurgical techniques can reduce skin and graft loss complications; nonetheless, such complications are still highly prevalent. We report a case of self-inflicted penile amputation and describe a nonmicrosurgical technique for replantation. To improve postoperative edema due to venous congestion, we applied medicinal leeches to the penis. The edema quickly resolved, but overlying skin loss occurred, which required superficial debridement. At follow-up the patient had glans re-epithelialization with normal voiding, sensation, and erections. To our knowledge, this is the first reported case of nonmicrosurgical penile replantation with leech therapy.     

Supramicrosurgical ear replantation: case report

Successful microvascular ear replantation is rarely reported, and most of the time involves the use of leeches for venous congestion. A case of microvascular replantation of the ear is reported in which two arterial inflow anastomoses and two outflow anastomoses (venovenous and arteriovenous) were performed. Postoperative, prostaglandin E1 (PGE1) was given. The replant was 100 percent successful, and no venous congestion developed.     

Salvage of replanted parts of the upper extremity

Twelve patients with fifteen replanted parts had vascular exploration in order to salvage the replantation after impending failure developed. Arterial occlusion only was found in eleven parts, while arterial and venous occlusion was found in the other four. Vein grafts were used in ten parts, with success in eight. Thrombectomy was done in six, with success in only one. It was possible to salvage nine of the fifteen replanted parts. The best results were obtained when the revision was done within eleven hours after the replantation.     

A technique for replantation of the finger tip

The finger-tip replantation technique reported here has evolved over 15 years. Indications for surgery include both strong patient desire and specialized use of the finger tip. Palmar flaps are elevated as full-thickness skin grafts to avoid injury to palmar veins. Arteries and palmar digital veins are repaired using an open-vessel technique. Postoperative care varies from immediate discharge with follow-up to inpatient care using surgical leeches or continuous bleeding as a method of drainage should venous congestion develop. The survival rate of 26 finger tips replanted using this technique between 1981 and 1987 was 69%. Two-point discrimination returned in 75% of patients, and 25% had two-point discrimination of less than 5 mm. The distal interphalangeal joint retained an average range of motion of 56 degrees. Appearance was excellent, and patient satisfaction was high.     

Automatic milking apparatus for the insufficient venous drainage of the replanted digit

An automatic milking apparatus composed of a finger attachment and a pump to push out the air was devised in order to perform the forced drainage from replanted digits with insufficient venous drainage. Seven replanted digits with insufficient venous drainage after replantation were applied, and remarkable improvement was found in five digits. An interesting case is reported in which a replanted digit without venous anastomosis survived as a consequence of applying the milking apparatus. The advantages of our milking apparatus are also discussed.     

Arteriovenous shunt as a method of restoring venous drainage in rabbit ear replantation

An arteriovenous (AV) shunt as a method of restoring venous drainage during replantation was examined by use of the rabbit ear model. The results were compared to ears replanted using one vein (1:1) or two veins (2:1) for venous drainage. The success rate for AV shunt replantations was found similar to that of replantations with a 1:1 ratio, but lower than that of ears with a 2:1 ratio. Postoperatively, ears replanted using an AV shunt or a 1:1 ratio revealed more swelling and lower tissue oxygenation than ears with a 2:1 ratio. After 10–14 days, all ears that survived were similar in appearance, regardless of method of replantation. Microscopic venules crossing the replanted interface appeared at seven days following surgery in all groups. The authors conclude that the AV shunt method offers an alternative to venous anastomosis when vein-to-vein reconstruction cannot be established. © 1994 Wiley-Liss, Inc.     

Microsurgical ear replantation without venous repair: failure of development of venous channels despite patency of arterial anastomosis for 14 days

The authors describe a case of microvascular ear replantation with repair of the artery only and medicinal leech therapy that survived for 14 days but ultimately failed as a result of the absence of development of venous channels between the replant and the recipient bed. A 35-year-old man presented with complete avulsion of 80% of the right external ear. The auricle was revascularized successfully via transposition of the superficial temporal artery (STA) and end-to-end anastomosis between the STA and an identified arterial branch on the posterior surface of the ear, using the technique of longitudinal wedge resection. No suitable veins could be found, therefore medicinal leech therapy was used for venous drainage as well as for systemic heparinization. Although the replant remained viable, frequency of leeching did not decrease over 2 weeks. On postoperative day 14, despite obvious viability of the replanted ear, leeching was stopped, considering the ongoing blood loss. Unfortunately, the auricle was found to be necrosed totally the following day. In retrospect, the authors think that inadequate debridement of nonvital tissues may have led to the failure of development of venous channels between the replant and the recipient bed, as manifested by the frequent requirement of leeching to relieve venous congestion long after revascularization. They conclude that the importance of thorough debridement cannot be overemphasized in microsurgical ear replantation with no vein anastomosis, as demonstrated in their patient. From the point of view of creation of venous drainage channels, deepithelialization of the posterior ear skin may be beneficial.     

The "chemical leech": intra-replant subcutaneous heparin as an alternative to venous anastomosis. Report of three cases

Three successful cases of distal finger replantation are described where suitable veins were unavailable for anastomosis after arterial flow had been re-established. To prevent infarction, calcium heparin was injected subcutaneously into the replants at intervals over 9 days. This allowed the venous blood to escape into the dressings while an adequate microvenous circulation was re-established, thus simulating the effect of a leech. Complete survival of all three distal replantations was observed. No attempted case has been unsuccessful. The procedure is simple and can be administered by the nursing staff. It avoids some of the problems associated with the use of medicinal leeches and systemic heparin. Applications of this technique in other areas of replantation and flap surgery are suggested.     

Single-vessel arteriovenous revascularization of the amputated ear

Successful single-vessel arteriovenous replantation of a completely amputated human ear is described. This result was followed by an experimental study using a rabbit model, to confirm that an amputated ear could survive replantation with only a single arteriovenous anastomosis. Fifteen animals were placed in one of two experimental groups: Group 1-arteriovenous replantation, no treatment (n = 6); and Group 2-arteriovenous replantation with medicinal leeching (n = 9). All ears demonstrated initial reperfusion of the replantation immediately following microanastomosis. Laser Doppler flow readings in the non-leeched replanted ears fell to zero by 8 hr and, by 12 hr, the non-leeched ears demonstrated signs of necrosis. All the leeched, replanted ears demonstrated perfusion and complete viability at the time of sacrifice. The case report, combined with the results from the experimental study, confirm that single-vessel arteriovenous replantation of an amputated ear is feasible.     

Survival of an upper lip aesthetic complex using arterial reanastomosis only

Venous congestion after microvascular replantation remains a formidable problem even under ideal circumstances. The patient reported is a young woman with a traumatically avulsed upper lip aesthetic complex. Blood flow was reestablished using microanastomosis of the labial artery, however, no veins of adequate size could be recovered. With systemic administration of heparin, allowing the flap to bleed freely in addition to the use of medicinal leeches, we were able to salvage an avulsed upper lip aesthetic complex with the use of a single arterial microanastomosis. This patient report exemplifies alternative methods used in dealing with venous inadequacy in a composite replant.     

Replantation of amputated facial tissues with microvascular anastomosis

A challenge to the microsurgeon is perfecting the technique of replantation of small pieces of facial tissue, mainly because of the extremely small size of the arteries as well as a lack of suitable veins for drainage. In the past 4 years, we have had seven cases of facial amputations, which included one scalp, two nasal tips, two ears, one lower lip, and one eyebrow. All of these patients were replanted/revascularized by microvascular anastomosis. Only two of the cases had suitable veins for anastomosis. Alternative techniques used for improving venous outflow were arterio-venous fistula, chemical leeches, and pin pricks. Four of the cases were completely successful, two cases had partial loss of the replant, and one case failed due to absence of venous drainage. In facial amputation, an aggressive microsurgical attempt will result in more tissue surviving and a better cosmetic outcome than in any other reconstructive procedures. © 1994 Wiley-Liss, Inc.     

Using an unconventional perfusion pattern in ear replantation—arterialization of the venous system

Ear amputation is a devastating injury characterized by a conspicuous deformity that is not easily concealed and can result in tremendous psychological trauma in addition to the physical insult. While numerous different approaches have been proposed, microvascular replantation is widely considered to deliver the best esthetic outcome. In this article, the authors report a case in which an unconventional perfusion pattern (i.e., arterialization of the venous system) was chosen, as intraoperative anatomic conditions precluded conventional vascular reconstruction. A 25‐year‐old male patient sustained a human bite resulting in subtotal amputation of his left ear. In the setting of an adequate arterial donor vessel, that is, branch of the posterior auricular artery, and a single suitable recipient vein (0.4 mm), the decision was made to perform an end‐to‐end arterio‐venous anastomosis without the use of vein grafts. Medicinal leeches were applied postoperatively to provide for venous drainage. The ear survived and the patient was discharged after 14 days. To the best of our knowledge, this is first case of a subtotal ear amputation that was successfully replanted by arterialization of the venous system without the use of vein grafts and with preservation of the superficial temporal vessels. © 2014 Wiley Periodicals, Inc. Microsurgery 34:657–661, 2014.