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.     

Evaluation of clinically applicable exsanguination treatments to alleviate venous congestion in an animal skin flap model

This study compares the effectiveness of alleviating venous congestion with mechanically-made outlets or leech therapy in promoting skin flap survival. Free flaps of abdominal skin (3 x 6 cm) were raised on Sprague-Dawley rats and subjected to ischemic events, simulating venous congestion. Animals received 1) no treatment; 2) two treatments involving two 18-gauge needle-puncture outlets; or 3) two sessions of leech therapy. Flap perfusion was monitored with a scanning laser Doppler flowmeter. Photographic images of flaps at 7 days were assessed for areas of normal tissue (n = 15), and laser Doppler flowmeter data consisted of control (n = 6), outlet (n = 6), and leech (n = 7). Both the needle-puncture outlet (40.0% +/- 9.24%) and leech treated (34.6% +/- 7.34%) groups had a significantly greater surviving skin area than untreated control flaps (8.0% +/- 5.0%), with 2 of 15 flaps receiving mechanical outlets exhibiting > 90% surviving area. After 7 days, laser Doppler flowmeter data showed greater mean perfusion in the outlet (71.7% +/- 16.8%) and leech (92.6% +/- 17.2%) treated groups, compared to controls (15.2% +/- 10.2%). There was a significant increase in perfusion in the outlet (13.3% +/- 6.2%) and leech (9.1% +/- 1.1%) treated groups from the end of secondary ischemia to day 7 (p < 0.05) compared to controls. The results suggest that two spatially separated outlets are as effective as one leech in increasing the area of surviving skin in venous congested flaps.     

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.     

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.     

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.     

The use of medicinal leeches in the salvage of flaps with venous congestion.

The use of medicinal leeches (Hirudo medicinalis) for the salvage of tissues with venous congestion has been intermittent over the last two centuries. During the last decade, interest in leech therapy has undergone a resurgence. Hirudo's tricuspid bite injects a highly potent anticoagulant. The site usually bleeds for 1 to 2 hours and under special circumstances may bleed for up to 24 hours. This collective series presents four patients in whom immediate postoperative venous congestion threatened the survival of three tissue replants and one latissimus dorsi flap. Two of the replants were completely salvaged; the other two failed due to infection. Hirudo medicinalis is an important adjunct in preventing flap or replant failure secondary to venous congestion, but its use is associated with significant risks.     

Ultrasound localization of a tunneled leech beneath a microvascular scalp reconstruction: A case report

Medicinal leech therapy is a common adjuvant modality used to treat venous congestion following threatened microvascular anastomosis. Migration and tunneling of a leech beneath a surgical reconstruction is a rare event that is seldom mentioned in the literature and worthy of further discussion. We present a rectus abdominus myocutaneous free tissue transfer that was used to cover a large alloplastic cranioplasty following resection of a previously radiated skull base malignant meningioma. The flap became congested postoperatively and required leech therapy after surgical salvage. Three days after flap salvage, the subject was once again brought back to the operating room for surgical exploration when a leech was witnessed to migrate beneath the threatened free flap. Duplex ultrasound was used intra‐operatively to localize the leech 12 cm from its bite and assist with its successful removal. Tunneling of the leech beneath the flap is a rare complication, and localization underneath a myofascial or myocutaneous flap may be difficult. Duplex ultrasound is a simple and reliable method to localize the leech and allow for its removal through a minimal access incision. © 2013 Wiley Periodicals, Inc. Microsurgery 33:572–574, 2013.     

Comparisons of medicinal leech therapy with venous catheterization in the treatment of venous congestion of the sural flap

Introduction: The originally described distally based sural flap technique has a risk of partial or total flap necrosis as high as 25%. The purpose of this study was to compare the medicinal leech therapy (MLT) with venous catheterization (VC) for blood volume removal, infection, wound dehiscence, and flap necrosis in the distally based sural flap with venous congestion. Patients and methods: Fifty‐six conventional distally based sural flaps with venous congestion during reconstructive surgeries were randomly divided into two groups, MLT group and VC group. The results of comparisons were analyzed using SPSS software (SPSS for Windows Ver.11.5). Results: There were significant differences in terms of the average volume of removed blood (53.6cc vs.172.2cc), infection (10.7% vs. 34.6%), wound dehiscence (10.7% vs. 42.3%), flap necrosis (3.6% vs. 19.2%), and nursing (7.8 vs. 5.19) and patient's satisfaction (8.03 vs. 5.6) in the VC group and MLT group, respectively. Although local heparin irrigation was performed in the VC group, the catheter was exchanged in 10 patients due to obstruction by clot. Conclusion: It is recommended that the VC be used for congested pedicled flaps instead of leech therapy, as VC is more effective, easy, and safe in blood removal, and it has less complication. © 2010 Wiley‐Liss, Inc. Microsurgery, 2011.     

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.     

The efficacy of medicinal leeches in plastic and reconstructive surgery: a systematic review of 277 reported clinical cases

Background: Although there are numerous case reports and small case series describing the experiences of leech therapy in various circumstances, there are relatively few large studies evaluating the effectiveness of leeching to relieve venous congestion. The therapeutic value of leeching is illustrated by these reports but the current literature lacks a cohesive summary of previous experiences. Methods: An electronic search of PubMed, the Cochrane library and the Centre for Reviews and Dissemination between 1966 and 2009 was used to retrieve human studies published in the English language evaluating outcomes following leech therapy. The “success” and “failure” of leech therapy were the primary outcome measures and secondary outcomes included complications, number of leeches used, pharmacological adjuncts and blood transfusion requirements. Results: In total, out of 461 articles, 394 articles met the exclusion criteria. The 67 included papers reported on 277 cases of leech use with an age range of 2–81 years and a male to female ratio of almost 2:1. The overall reported “success” rate following leech therapy was 77.98% (216/277). In terms of secondary outcome measures, 49.75% of cases (N = 101) required blood transfusions, 79.05% received antibiotics (N = 166) and 54.29% received concomitant anticoagulant therapy. The overall complication rate was 21.8%. Conclusion: In the absence of robust randomized controlled trials on which the evidence may be based, this synthesis of current best evidence guides clinicians during the process of consenting patients and using leeches in their practice. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Chemical and mechanical alternatives to leech therapy: a systematic review and critical appraisal

Although leech therapy is a well-established, effective method of relieving venous congestion, it is associated with complications such as wound infection and leech migration. To minimize these risks, efforts to reproduce their effects have been developed and investigated. A search string using (chemical OR mechanical OR alternative) AND (Leeches OR HIRUDO MEDICINALIS) in Boolean format was used across the major electronic databases to cover the past 10 years. Selected references were subsequently validated against critical appraisal frameworks and classified and evaluated against a framework of hierarchies of evidence. Out of 95 retrieved studies, 25 articles were selected after content appraisal. Of these, 12 articles were methodologically and statistically robust. The heterogeneity noted in the studies precluded meta-analysis of the results. The studies infer evidence at Grade B level that current device prototypes show proof of concept by providing suction and chemical anticoagulation following a surgically created wound. Although progress had been made to replicate leech action, there are still areas to address in future research. This article represents the current state of play in clinical translation of these concepts, providing efficacious devices without the drawbacks of traditional leech therapy.     

The role of leech water sampling in choice of prophylactic antibiotics in medical leech therapy

Medical leech therapy (MLT) with Hirudo medicinalis is well established as a treatment for venous congestion of tissue flaps, grafts, and replants. Unfortunately, this treatment is associated with surgical site infections with bacterial species, most commonly Aeromonas hydrophila, which is an obligate symbiot of H. medicinalis. For this reason, prophylactic antibiotics are recommended in the setting of MLT. After culturing Aeromonashydrophila resistant to ciprofloxacin from a tissue specimen from a patient with a failed replant of three digits post‐MLT, we performed environmental surveillance cultures and antibiotic susceptibility testing on water collected from leech tanks. This surveillance was performed twice weekly for 2.5 months. Fourteen surveillance cultures demonstrated 21 isolates of Aeromonas species, 71.4% of which were ciprofloxacin susceptible. All isolates were sulfamethoxazole‐trimethoprim (SXT) susceptible. The prophylactic antibiotic regimen of choice for leech therapy at our institution is SXT, with culture of tank water to refine antimicrobial choice if necessary. This study demonstrates the importance of regular surveillance to detect resistant Aeromonas species in medical leeches; however optimal practice has not been established. © 2013 Wiley Periodicals, Inc. Microsurgery, 2013.     

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.     

Microsurgical replantation and postoperative leech treatment of a large severed nasal segment

Abstract

The survival of a microsurgically replanted segment of nose in a 41-year-old woman was facilitated by the assistance of the medicinal leech Hirudo medicinalis. An arterial microanastomosis was made to a severed partial segment of nose with no possibility of recreating a venous anastomosis. The resulting venous congestion was treated with nine days of treatment with a medical leech until venous neovascularisation had been achieved. At follow-up six months after discharge there was a well-heeled nasal segment and a satisfying functional - as well as cosmetic - result.     

Technical recommendations for penile replantation based on lessons learned from penile reconstruction

Penile amputation is an exceptional surgical emergency. Immediate replantation yields a high success and low complication rate. We report a case of a self-inflicted penile amputation treated with successful microsurgical replantation. Postoperative edema caused minor skin slough and temporary venous congestion was treated with medicinal leech therapy. Follow-up at 18 months showed normal subjective sensation; voiding and erectile function were present. Surgical management and technique refinements are discussed, based on a review of the literature and on our experience in penile reconstruction.     

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.     

Determining the appropriate number and duration of leech therapy in congested tissues using tissue spectrophotometry and laser Doppler flowmetry

A universal protocol determining the number of leeches and their application time does not exist. The aim of this study, therefore, is to quantify perfusion dynamics in venous congested tissues after leech application to get more detailed information about changes due to leech‐induced skin microcirculation and to evaluate the usability of the Oxygen to See (O2C) device in terms of determining the appropriate number of leeches and the duration of therapy. Twelve patients with the need for leech therapy participated in the study. Perfusion dynamics of the congested tissue was assessed using the O2C device, which determines blood flow (BF), the relative amount of hemoglobin (rHB), and the oxygen saturation (SO2). Measurements were carried out before leech application and on various intervals like 10 minutes, one hour, and three hours after leech application. The leech application effectuated after 10 minutes a nonsignificant perfusion improvement, which further increased after one hour with a significant reduction of the relative amount of hemoglobin and a significant increase of blood flow and oxygen saturation (BF= +56.7%; rHB= ?25.5%; SO2= +53.7%). After three hours, the values returned to the levels before leech administration. In two cases, in which further administration of leeches within the measurement period was necessary, no substantial perfusion changes were obtained. The results of this study forms a more precise pattern of microcirculatory changes of leech therapy in congested tissues. According to our measurements a venous drainage improvement can be expected in congested tissue one hour after leech administration. The O2C seems to be a useful method to determine the appropriate number and duration of leech therapy.     

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.     

Leech therapy and bleeding wound techniques to relieve venous congestion

Temporary restoration of capillary skin blood flow can be established by using leeches or by the creation of a dermal wound and the promotion of continued bleeding from the wound site in a flap with venous occlusion. An increasing restoration of capillary flow occurred with initial application of the leech and tended to exceed other techniques of restoring flow. However, all techniques of exsanguination, including leech therapy, restored very low perfusion over a two-hour course of therapy for a volume of tissue simulating a distal finger replant. The temporary increase in flap perfusion with a single leech application was greatest during the feeding activity of the leech and tapered off after the leech was satiated, to approximate flows achieved with local heparin injection and a punch wound.