Leeches are used in modern medicine for skin and tissue grafts
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Peer-reviewed literature demonstrates that medicinal leeches are commonly used in modern plastic and reconstructive surgery to relieve venous congestion and promote the success of skin and tissue grafts.
<h4>Introduction</h4>Medicinal leeches have been part of the therapeutic armamenterium of plastic surgeons for more than 50 years. While their use in hand surgery is a matter of course, their use in salvage of flaps with venous congestion remains facultative depending on teams.<h4>Materials and methods</h4>We conducted a systematic review of leech therapy for flap salvage between 1960 and 2015, analyzing 121 articles and subsequently taking into consideration 41 studies. In parallel, we collected data from 43 patients for whom leach therapy had recently been applied in treatment of venous insufficiency in pedicled or free flaps after revision surgery had failed to improve flap vascularization, or in cases where flap revision was not appropriate. The data collected pertained to relevant indications, treatment procedure, efficacy, adjuvant therapies, side effects and complications.<h4>Results</h4>For this indication, the success rate of leech therapy ranged from 65 to 85% (83.7% in our series) according to the situations encountered. Optimal frequency of application ranged from 2 to 8hours, while average overall duration ranged from 4 to 10 days. The number of leeches to be applied can be determined depending on volume of the flap. In 50% of the cases reported in the literature, the patients required transfusion. Antibiotic prophylaxis against Aeromonas is highly advisable. A ciprofloxacin and trimethoprim-sulfametoxazole combination currently appears as the most relevant prophylactic antibiotherapy.<h4>Conclusion</h4>Hirudotherapy is a reliable treatment in cases of patent venous insufficiency of pedicled or free flaps (or when revision surgery is not recommended). Even though the relevant literature is highly heterogeneous, we have attempted to put forward a specific protocol bringing together dosage, delivery route, frequency of administration and appropriate prophylactic antibiotherapy. An algorithm for treatment and management of venous congestion and a practical information sheet have been placed at the disposal of plastic surgery teams.
Summary: Medicinal leeches are a US Food and Drug Administration-approved treatment for venous congestion in graft tissue to promote healing and can serve as a nonsurgical option for plastic surgery patients with concern for tissue compromise. Although there is a wealth of documentation on medicinal leech therapy, the surgical space currently lacks an updated summary of proper indications, use, and risks as they pertain to plastic surgical patients. The purpose of this article is to provide a platform for understanding the recent literature as it relates to reconstruction to improve understanding of indications and necessary considerations in using hirudotherapy. Topics examined include basics of hirudotherapy, indications in plastic surgery, implementation (leech application, number and duration of therapy, and removal), risks (infection and bleeding), and alternative treatments. The evidence provided will aid in physician understanding and implementation, patient counseling, and the informed consent process.
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.
Background: The medicinal leech has been used in plastic surgery to resolve venous congestion that can threaten the viability of tissue transfer. Within the context of breast surgery, venous congestion is a pertinent consideration for reconstructive and non-reconstructive breast surgery such as mammoplasty and mastopexy. However, leeching is closely associated with complications such as infection, pain, and anaemia. This is the first systematic review that examines the methodology, efficacy, and post therapeutic outcome data across all existing studies on medicinal leeching in breast surgery. Methods: A systematic search of PubMed and Embase databases from their inception to November 2023 was conducted. Inclusion criteria included studies reporting on the use of leeches to resolve venous congestion in any breast surgery. The JBI Critical Appraisal Checklist for Case Series tool was used for bias analysis. Descriptive statistics were undertaken in Microsoft Excel. Results: A total of 18 studies with a combined sample size of 28 were examined, including 4 case series and 14 case reports. Patients mostly underwent reconstructive breast surgery (75%). The median number of leeches used was two, with a median number of three leeching sessions per day and 3 days of leeching. Medicinal leeching successfully prevented the loss of 75% of all tissue transfers. The complication rate was high at 81.14% and mainly included infection and anaemia. Conclusions: Medicinal leeching is an effective method to relieve venous congestion in breast surgery but must be judiciously used within the clinical context of the patient to maximise efficacy and mitigate harm from complications.
Aeromonas hydrophila infection associated with the use of medicinal leeches.
The use of medicinal leeches (Hiruda medicinalis) is becoming more common after plastic surgery to control venous congestion of skin grafts. We describe a patient with Aeromonas hydrophila infection whose graft was treated with medicinal leeches. The infection required systemic antibiotic therapy. A. hydrophila is the predominant bacterial flora in the gut of the leech, where it plays an essential role for the animal in the digestion of blood. The potential for A. hydrophila wound infection, and appropriate antibiotic prophylaxis of the leech or patient, should be considered when medicinal leeches are used.
Published in Journal of clinical microbiology (1989)
Aeromonas, acclimation, and penicillin as complications when leeches are applied to skin flaps in rabbits. The medicinal leech, Hirudo medicinalis, has been recognized by plastic surgeons for its ability to reduce congestion and improve blood flow in grafted skin flaps by withdrawing excess blood. The leech's ability to digest blood is due to the presence of Aeromonas hydrophila in the gut of the leech. In this report we describe the occurrence of Aeromonas hydrophila septicaemia in rabbits used in a study to evaluate the efficacy of the medicinal leech on abdominal skin flap survival. In New Zealand White rabbits, twin 5 x 10 cm abdominal skin flaps were prepared and the epigastric vein was ligated to produce a model of venous congested skin. After 12 hours, a leech was applied to one of the congested abdominal flaps and skin survivability was assessed and compared with the unleeched flap. Five rabbits died acutely approximately 24 hours post-operatively. Gross necropsy, bacteriology and histopathology findings indicated that A. hydrophila was the causative agent of the septicaemia-toxaemia syndrome with an associated pneumonia and typhlitis.
The Unani System of Medicine also known as Greeko-Arab medicine, founded by Hippocrates is based on the concept of equilibrium and balance of natural body humours (blood, bile, black bile and phlegm). The imbalance in the quality and quantity of these humours leads to diseases whereas restoration of this balance maintains health of a person. The treatment methodology of diseases is based on four therapeutic modalities viz. Regimental therapy, Dieto-therapy, Pharmacotherapy and surgery. Irsale Alaq (Leech or Hirudo therapy) is one of the most important and widely practised methods of regimental therapy used for local evacuation of morbid humours. It is a procedure of treatment with the use of medicinal leeches. It has been suggested and successfully practised by Greeko-Arab physicians in the management of musculoskeletal diseases, gynaecological disorders, chronic skin diseases, thromboembolic diseases, varicose veins, ENT disorders etc since long. According to Unani doctrine, the efficacy of leech therapy is attributed to the analgesic and resolvent activities of leeches. However, from modern perspective, the saliva of leech contains about 100 pharmacologically active biological substances like Hirudin, hyaluronidase, vasodilators, anesthetics, antibacterial, fibrinases, collagenase etc. These substances are injected into human body while sucking of the blood and are responsible for the analgesic, anti inflammatory and anesthetic effects of leech therapy.
The bioactive compounds that are produced by leeches combine traditional and modern treatment since the saliva of the animal contains proteins and peptides with anticoagulant, anti-inflammatory, antimicrobial, antioxidant, and regenerative properties. In this review, their biochemical profile, mechanisms and clinical uses are considered with a special focus on the fact that they are utilized to combine traditional practices with the modern developments in biomedical approaches. Proteomic and transcriptomic research has recently found more than 100 bioactive molecules, such as hirudin, calin, eglins, bdellins and destabilase, which are related to the blood-feeding process and therapeutic processes. These compounds control blood clotting, control inflammatory mediators, block microbes and enhance wound healing and the development of new blood vessels. In clinical practice, leech therapy is common in the reconstruction and microsurgical practice to reduce venous congestion and enhance graft success. They are also shown to be useful in wound healing, cardiovascular health, musculoskeletal conditions and regenerative medicine, as well as emerging drug delivery systems of recombinant proteins and nanocarriers. Some of the challenges involve biological variation, infection or bleeding risks and stringent regulations on purity and standardization. Biotechnology has improved through other developments such as recombinant protein production, high-throughput omics, and nanotechnology, which will help resolve these problems, making them safe and scalable for clinical use. Altogether, leech bioactives are the prime examples of the sophisticated pharmacology of nature, which have the potential of being used as therapeutic agents in the future. The recent approach and incorporation in personalized medicine and bioengineering models reflect the leech's capacity to address complicated illness and unmet healthcare requirements to reassert its significance in preventive medicine and recent biomedicine.
Jalaukavacharana is the ancient technique used for Raktmokshana, here Jalauka means leeches and avacharana means application. Jalauka is one of the tools for Raktmokshana, among Shring, Alabu and Prachhana where Jalauka, Shring, Alabu are used for Pitta, Vata, Kahpa Doshaj Vyadhi respectively. Jalaukavacharana (leech therapy) is a non-surgical type of Raktamokshana and considered as the most unique and effective method of bloodletting. A lot of research work has been carried out in Ayurveda and Modern medicine to prove efficacy of leech therapy in various disorders. Leeches are widely used in most of the disorders ranging from skin disease to Ischemic heart disease with evidence of successful results. In the present paper effort has been made to review various scientific studies which have been conducted in Ayurveda as well as Modern medicine and study the indications of Jalaukavacharana in various disorders as per Ayurveda and Modern medicine. This paper also studies the possible complications of Jalaukavacharana. Keywords: Jaloukavacharana, Raktmokshana, Leech therapy, Bloodletting, Hirudo therapy.
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