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Science Forum Index » Medicine - Cancer Forum » Role of the Medicinal Leech
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 Posted: Wed Dec 13, 2006 3:49 pm |
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http://www.laryngoscope.com/pt/re/laryngoscope/abstract.00005537-199808000-00005.htm;jsessionid=FQXY1Y2nX9QlkmK1JjS9hJWnhntQkTMB2TZ7YTW7hpcZP9TV6L5k!-2066534216!-949856144!8091!-1
The Failing Flap in Facial Plastic and Reconstructive Surgery: Role of the
Medicinal Leech.
Triological Society Papers
Laryngoscope. 108(8, Part 1):1129-1135, August 1998.
Utley, David S. MD; Koch, R. James MD; Goode, Richard L. MD
Abstract:
Objective: To review the use of the medicinal leech, Hirudo medicinalis,
in salvaging the failing, venous-congested flap. A protocol for the use of
leeches is presented. Four illustrative cases of failing flaps (pectoralis
major, midline forehead, and temporalis) are presented.
Study Design: Literature review comprised of MEDLINE search 1965 to
present. Retrospective review of four cases involving the management of
the failing, venous-congested flap.
Methods: A retrospective review of four cases of failing, venous-congested
flaps was performed.
Results: The authors' experience, as well as the data from the reviewed
medical literature, demonstrates the importance of early intervention in
order to salvage the failing, venous-congested flap. Leeches are an
immediate and efficacious treatment option.
Conclusions: 1. Review of the literature indicates that the survival of
the compromised, venous-congested flap is improved by early intervention
with the medicinal leech. H medicinalis injects salivary components that
inhibit both platelet aggregation and the coagulation cascade. The flap is
decongested initially as the leech extracts blood and is further
decongested as the bite wound oozes after the leech detaches.
2. When a flap begins to fail, salvage of that flap demands early
recognition of reversible processes, such as venous congestion. The
surgeon must be familiar with the use of leeches and should consider their
use early, since flaps demonstrate significantly decreased survival after
3 hours if venous congestion is not relieved. In the four cases presented,
a standardized protocol facilitated early leech use and provided for the
psychological preparation of the patient, availability of leeches, and an
antibiotic prophylaxis regimen.
3. The complications associated with leech use can be minimized with
antibiotic therapy, wound care, and hematocrit monitoring.
4. The use of the medicinal leech for salvage of the venous-congested flap
is a safe, efficacious, economical, and well-tolerated intervention.
(C) The American Laryngological, Rhinological & Otalogical Society, Inc.
http://jncicancerspectrum.oxfordjournals.org/cgi/content/full/jnci;91/20/1714
Journal of the National Cancer Institute, Vol. 91, No. 20, 1714-1716,
October 20, 1999
© 1999 Oxford University Press
NEWS
Leeches Latch on After Reconstructive Surgery
The very sight of them may be off-putting, but for patients in trouble,
medicinal leeches are just what the doctor ordered.
In an apparent anachronistic twist of contemporary medicine, plastic
surgeons are relying on these large worms to rescue skin flaps compromised
by venous congestion after surgery. Many clinicians use these blood
suckers only in a last ditch effort to stave off tissue death or necrosis
following reconstructive procedures, including those for cancer. However,
proponents of leech therapy say that surgeons should be less hesitant to
use them prior to a grave threat to the surgical site.
Known as Hirudo medicinalis, the medicinal leech, which costs about $7 per
worm, is used most often after trauma, such as the loss of a finger or
limb.
Today's plastic surgeons usually call upon them once other methods to
decrease venous congestion, such as pricking the skin with a needle or
using nitropaste (a cardiac drug that dilates blood vessels), have been
exhausted. "We don't want to use them unless we have to," said Ronald M.
Friedman, M.D., a plastic surgeon in private practice in Plano, Texas.
"It's a salvage situation."
Reattaching a digit and reconnecting its blood vessels is painstaking work
that is often carried out under the microscope. Problems with
reestablishing blood flow occur about 10% of the time when "we can get the
artery hooked up, but not the vein," explained Louis P. Bucky, M.D., a
plastic and reconstructive surgeon at the University of Pennsylvania in
Philadelphia.
Similarly, a tram flap, abdominal tissue used to create a new breast after
a mastectomy, may also become engorged with blood that cannot find its way
out of the affected area. Leeches work by "removing extra venous blood and
increasing blood flow" to the region, according to Ira D. Papel, M.D., a
plastic surgeon in private practice in Owings Mills, Md., and associate
professor at John Hopkins University, Division of Facial Plastic Surgery,
in Baltimore.
"If we can't get the vein to remain open after surgery," said Bucky, "then
the patient will run into trouble. We can leech the tissue, so that it can
continue to bleed a little bit until the venous blood vessels can hook up
and survive."
By the time a leech arrives in the hospital pharmacy, it "is hungry and
ready for a blood meal," said Lawrence Wallace of Carolina Biological
Supply Company, Burlington, N.C., sole distributors of laboratory-raised
medicinal leeches in the United States for the Welsh company Biopharm.
Once the 1- to 2-inch long worm is nudged into position on the wound, it
can consume up to five times its body weight in blood, approximately 10
milliliters in an hour or less. The animal's bite does not hurt, possibly
due to the anesthetic compounds in a leech's saliva.
During its feast, the leech injects an anti-coagulant, known as hirudin,
into the wound, which contributes to sustained bleeding of the affected
site for 5 to 6 hours after the leech falls off on its own or is removed.
Once it is finished dining, the leech is disposed of like medical waste.
Hirudin, which was isolated in the leech in the 1950s, has raised
awareness of the leech outside the field of plastic surgery. Enzymes
present in its saliva dissolve blood clots and inhibit platelet
aggregation, which has led to the creation of drugs like Refludan
(lepirudin), a recombinant protein used to treat heparin-induced
thrombocytopenia (Hoechst Marion Roussel, Kansas City, Mo.).
There are potential hazards associated with leech therapy, such as
infections caused by bacteria from the leech's gut. Yet, according to
Papel, the commercial availability of the animals has dissipated many
surgeons' fears that leeches will infect their patients.
Out of Sight
Excessive bleeding that requires a blood transfusion is another risk
people undergoing leech therapy may face. While Bucky said patients "are
remarkably understanding and reasonable about leeches," they are
nevertheless apprehensive initially about having them applied to their
bodies. In light of this, Bucky will erect a tent to keep the homely worm
out of a patient's line of vision.
Friedman agrees with Bucky's assessment of patients' willingness to accept
this unique therapy despite their reluctance. One of Friedman's patients
who underwent reconstructive surgery for cancer of the vulva "was not very
excited about the leeches and only agreed to let me use them if she didn't
feel or see them." In the end, the woman kept her sunglasses on to prevent
her from catching a glimpse of the animals crawling on her thigh.
Popularity Poll
There are signs that leeches are gaining in popularity. Wallace estimates
that since the introduction of Biopharm's medicinal leeches to the U.S. in
the mid-1980s, sales have increased every year. Now, said Wallace,
Carolina Biological Supply Company sells "several thousands per year."
Still, according to Friedman, leech therapy is rarely discussed in medical
school, meaning doctors are left to just "figuring it out" on their own.
"The first time you see the leeches, you think whoever is putting them on
[the patient] is crazy," he said, before noting that at times, "people
tend to use them too late."
"If you have to use them," said Friedman, "don't waste time. Despite our
advanced surgical techniques and therapies, there's still nothing better
than leeches to solve the problem of venous congestion. I have a lot of
respect for the little guys." |
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