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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 57  |  Issue : 1  |  Page : 55-59

Leech as a lifeboat: Reminiscent role in plastic and reconstructive surgery!


1 Department of General Surgery, SBH GMC, Dhule, Maharashtra, India
2 Department of Oral Medicine and Radiology, ACPM Dental College, Dhule, Maharashtra, India

Date of Web Publication10-Jun-2019

Correspondence Address:
Dr Ujwala Rohan Newadkar
Department of Oral Medicine and Radiology, ACPM Dental College, Dhule - 424 003, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_16_19

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  Abstract 


Leeching was a popular therapeutic practice since ancient times for various diseases. Previously, it was used as an unscientific home remedy by traditional therapists. Currently, leech came back to contemporary medicine with few applications, which were demonstrated and held by an enormous number of scientific studies and case reports. Leeches are worms of the Phylum Annelida that feed on blood extracted from a host. Medicinal leeches have been evidently revealed to have a role in reconstructive surgery and replantation surgery. Literature exhibited the use of leeches in microsurgeries such as in skin flaps, replantation of amputated tissues of face, scalp, ears, fingers, and penis. Leech therapy increases the blood flow and neovascularization. This article highlights the comprehensive importance of leech therapy in the clinics of plastic and reconstructive surgery.

Keywords: Hirudotherapy, leeches, microsurgeries, skin flaps


How to cite this article:
Newadkar RD, Newadkar UR. Leech as a lifeboat: Reminiscent role in plastic and reconstructive surgery!. TNOA J Ophthalmic Sci Res 2019;57:55-9

How to cite this URL:
Newadkar RD, Newadkar UR. Leech as a lifeboat: Reminiscent role in plastic and reconstructive surgery!. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2019 Aug 24];57:55-9. Available from: http://www.tnoajosr.com/text.asp?2019/57/1/55/259877




  Introduction Top


There are a small number of blood-sucking species used in traditional and modern medicine which is known as a medicinal leech. Leech therapy (Jalaukavarchana or Hirudotherapy) has been mentioned as a type of bloodletting (Raktavsechan). The US-Food and Drug Administration (FDA) approved the use of leeches in plastic and reconstructive surgery in 2004.[1],[2] Legislation on “Traditional, Supplementary, and Alternative Medicine Practices,” including the use of leeches in medicine, went into effect in 2014 in Turkey.[3] According to the regulation, using only cultured leeches (Hirudo medicinalis and Hirudo verbana) are permitted in medical treatment. This article highlights the comprehensive importance of leech therapy in the clinics of plastic and reconstructive surgery.


  Historical Perspective Top


In ancient Greek history, bloodletting was practiced according to the humoral therapy. It is proposed that when the four humors namely blood, phlegm, black, and yellow bile in the human body were in balance, good health was guaranteed. An imbalance in the proportions of these humors was believed to be the case of ill health. Records of this theory were found in the Greek philosopher Hipocrate's collection in the 5th century BC. Bloodletting using leeches was the method used by physicians to balance the humors and to rid the body of the plethora.[4] The first known use of leeches dates to 3500 years ago in Egypt, where a tomb painting depicted the application of leeches by a barber-surgeon. Detailed documentation of leeching also dated to 3300 years ago in India. In the west, leeches were first used for medicinal bloodletting 2200 years ago by Nicander of Colophon, Greece. By the end of the 19th century, the leech had lost its popularity. Haycraft brought leeches back into mainstream thinking with his discovery in 1884 that a pure anticoagulating preparation was contained in the saliva of leeches which he named “Hirudine” from the Latin “Hirudo.”[5]


  Anatomy and Mechanism of Leeching Top


Leeches belong to the Phylum Annelida, the segmented worms. The name, introduced by Grube (1850), is derived from the Latin annelus or annellus (diminutive of anulus), meaning “little ring” and referring to the external ringed appearance of the worms. Leeches are also placed in the class Hirudinea (from Latin for leech, Hirudo) in the Subphylum Clitellata, together with the class Oligochaeta (earthworms and other detritus feeders). The name is derived from the Latin clitellum, meaning “saddle” and referring to the broad, swollen ring that is clearly visible in mature earthworms.[6] All leeches are either predatory or parasitic carnivores or their brain and sense organs combined with a flexible, muscular body enable them to actively pursue their prey. They have been described as “worms with the character”.[7]

Hirudotherapy depends on the following main properties of medicinal leeches: the bloodletting action during active suction of blood, passive oozing of the wound, and injection of biologically active substances with the saliva into the host. The saliva of the leech consists of anesthetic agents, anticoagulant, antiplatelet aggregation factor, antibiotic, anti-inflammatory substances, and gelatinous substances[8],[9],[10],[11] [Table 1]. A medicinal leech, once attached, will extract eight to nine times its body weight, approximately 20 mL of blood. Once the leech has fallen off an additional amount is lost via slow but continuous flow over the next 48 h because of a localized anticoagulant effect.[12] Leeches are fast and elegant swimmers in water (”sweet water dolphins”). Moreover, they can move rapidly on the patient's skin as well. To apply them correctly, a 5 ml syringe where the nozzle was removed by scissor can be used. The leech is placed into the prepared syringe, and the syringe is directly applied on the skin surface to be treated with its open end. When the leech is feeding, the syringe is removed.[2]
Table 1: Components of leech saliva and their functions

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Recent applications of leeching

Leech therapy is usually initiated after the failure of more conventional treatment modalities such as warming, aspirin, rheomacrodex (intravenous), immobilization and elevation of the injured area, and use of local heparin and vasodilators to improve the venous status. Leeches are used for the treatment of chronic wounds, postphlebitic syndrome, and inflammatory skin diseases. Leeches have also been used successfully to decongest replanted parts, including completely avulsed ears and digits and partially avulsed segments of the lip, penis, nose, and scalp. They also have been used on threatened digits in purpura fulminans, ear and periorbital hematomas, and traumatically degloved tissues, and in the salvage of nipple necrosis in breast reduction procedures.[13]

Role of leech therapy in plastic and reconstructive therapy

In 1980, medicinal leech therapy got a big boost by plastic surgeons that used leeches to relieve venous congestion, especially in transplant surgery.[14] In 1985, at Harvard University, one of the physicians had great difficulty in reattaching the ear of a 5-year-old child, the tiny veins kept clotting, he decided to use leech while feeding it they inject salivary component which inhibits both the platelet aggregation and coagulation escalade, thus realizing the venous congestion and induces revascularization. Hence, it is effective in plastic surgery.[15] Leeches have been used to aid wound healing after plastic surgery. In certain parts of the world, leeches are commonly applied to treat venous congestion at surgical wound sites. Leech therapy is appropriate in plastic surgical situations in which there is more arterial repair than venous repair, such as fingers, auricles, and skin flaps.[8]

  1. Flaps: medicinal leeches are recognized in the treatment of venous congestion or complete venous outflow obstruction in larger pedicled flaps and microvascular transfers. It is necessary to differentiate the origin of the insufficiency of the flap [Table 2]. Medicinal leeches may be helpful in treating tissues with venous insufficiency by establishing temporary venous outflow until graft neovascularization takes place.[16] In July 2004, the FDA approved leeches as a medical device in the field 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 uses leeches postoperatively[17] [Table 3]
  2. Postoperative pain management: leeches are used in pain syndromes of various origins. The pain relief is rapid and sometimes long-lasting.[33] There are reports on successfully leech therapy in severe cancer pain.[34] Studies in osteoarthritis argue for symptomatic improvement by leech therapy by analgesic and anti-inflammatory effects[35],[36]
  3. Hematoma: medicinal leeches are used to drain a hematoma (a collection of partially clotted blood) from a wound, the most obvious examples being a “black eye,” a “cauliflower ear,” “gum boils,” and “minor ulcers.”[37],[38],[39] The use of leeches to reduce a periorbital hematoma is not new and was described by Oristasius in 330 AD.[40] The treatment aims to counteract tissue ischemia, hypoxia, acidosis, necrosis, and gangrene. The possible mechanism of action of leech therapy is based on the anticoagulant properties of hirudin (contained in leech saliva) and the capacity of the leech to suck the blood, thereby relieving the pressure in the affected compartment.[41] In particular, medicinal leeches have been very effective in regions with diffusely spreading hematomas such as in the tongue or scrotum.[42],[43] Heckman et al. showed the use of Leech therapy in the treatment of median nerve compression due to forearm hematoma[44]
  4. Varicose veins and ulcers: application of medical leeches for the treatment of varicose leg ulcers decreased edema, limb girth, and improved ulcer healing. There are case reports on the successful use of medical leech therapy for diabetic foot ulcers to salvage the leg.[45]
Table 2: Differentiation between arterial and venous insufficiency of the flap

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Table 3: Literature on the use of leech therapy in the plastic and reconstructive surgery

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  Safety and Complications Top


Contraindications for leech therapy are mentioned in [Table 4].[46] Prolonged bleeding of up to 10 h can be observed from time to time after medical leech therapy.[47] Episodes of syncope due to anemia from leech therapy can be encountered. Thus, it is of utmost importance to keep a check on patients' hemoglobin level frequently and transfusing appropriately. Signs of regional lymphadenitis, slight swelling, and pain of regional lymph nodes on the side of leech application and sub febrile temperature can occur in 6.4%–13.4% of the treated patients and usually appears after 3–4 leech applications. Other complications include excessive blood loss requiring transfusion, scarring from leech bites (Y-shaped bite site), local hypersensitivity reaction, anaphylaxis, development of inflammatory epidermal cysts, development of diffuse pseudolymphoma, and local irritant contact dermatitis.[48] Aeromonas infection secondary to treatment with leeches may occur and should be treated promptly with proper antibiotic coverage such as second-generation or greater cephalosporins, aminoglycosides, trimethoprim-sulfamethoxazole, or ciprofloxacin.[49]
Table 4: Contraindications related to leech therapy

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  Conclusion Top


Medicinal leeches have an important role in the management of traumatic and microvascular flaps. In cases, when flap failure is certain, leeches can be used as an alternative method for reestablishing venous outflow until inosculation occurs. The adverse effects of leech therapy warrant the risk of Aeromonas infection and anemia. Surgeons should weigh the benefits of such treatment before introducing any other costly or difficult treatment modalities. This article assembles the successful use of leeches for various conditions in the plastic and reconstructive surgery from the literature.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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