The use of the medicinal leech, Hirudo medicinalis, in the reconstructive plastic surgery

摘要

The medicinal leech, Hirudo medicinalis, is being used to salvage compromised microvascular free-tissue transfers, replanted digits, ears, lips and nasal tips due to venous congestion. Twenty-three patients, 8-79 years old presenting with venous congestion of revascularized or replanted fingers, free or local flaps were treated by leech therapy. Of the 15 fingers, 10 fingers were saved (4 out of 9 replanted fingers and 6 out of 6 revascularized fingers), while 17 out of 18 flaps were salvaged (3 out of 4 free flaps and all 14 island and random flaps). Fifteen patients received 1-13 units of packed blood cells (average 2.9). The patients with revascularized or replanted fingers were treated in average of 2.5 days and each finger was treated with an average of 5.7 leeches. The 15 patients with flaps were treated in average of 3.4 days and each flap was treated with an average of 9.2 leeches. Introduction In recent years, the medicinal leech, Hirudo medicinalis, has been used to aid salvage of compromised microvascular free-tissue transfers, replanted digits, ears, lips and nasal tips in the plastic surgery [1]. The survival of compromised, venous-congested tissues was improved by early application of leeches [2,3,4].In July 2004, the FDA approved leeches as a medical device in the area of plastic and reconstructive surgery. A survey of all 62 plastic surgery units in the United Kingdom and the Republic of Ireland showed that the majority of these units use leeches post-operatively [1]. In Israel, most of the studies on leeches are about the anti-coagulant properties of the leech saliva [5, 6]. Eldor et al. [7] used this technique on 50 patients with congested skin flaps and in one patient with a reimplanted ear, as well as in 40 patients with post-phlebitic syndrome. In 52.5% of the patients the pain-relief was immediate and persisted for about three weeks while improved mobility was reported in 70% of them. Shenfeld [8] used leeches for the treatment of venous insufficiency in a replanted digit.We report the use of leeches in 23 patients with venous congestion either after revascularized or replanted fingers or after flap reconstructions. Patients and methods LeechesThe medicinal leech, Hirudo medicinalis, was purchased from France (Ricerimpex SAS, Cardolle, France). The leeches were kept at 5-6 o C in de-chlorinated water, which was changed twice a week. At these conditions, leeches survive up to two years without feeding. One to two gram heavy leeches were used for all treatments, and they were kept at room temperature for 1/2 – 1 hr before being transferred to the skin of the patient.Treatment procedureThe area to be exposed to leeches was cleaned with sterile distilled water. Leeches were placed on the region of the removed nail for fingers or on the darker spots when dealing with flaps. The animals normally started feeding immediately, although in rare cases the skin was punctured with a sterile needle so that oozing blood would stimulate the leeches to feed.The leech was placed on a given spot of the skin using a 5 ml syringe. For this purpose, the plunger of the syringe was removed with the help of a scissor or scalpel. The leech was placed in the barrel of the syringe and the open proximal end of the syringe was placed on the area to be treated. When the leech started feeding the syringe was removed. Feeding lasted for 45-120 minutes, and during this time the leech was monitored by one of the authors or a nurse. After auto-detachment, the leeches were killed in 70% ethyl alcohol and were disposed of in bags for biological waste. The bite area was cleaned every 3-4 hours with a gauze sponge soaked in physiological saline to remove any locally forming clot and with a heparin (5,000 U/ml) soaked gauze, to increase the time of blood oozing. One to 5 leeches were used for each session of treatment. PatientsTwenty-three patients (14 male and 9 female), 8-79 years (average: 35.9 years) old with devascularized or amputated fing